When you opt for Medicare Advantage instead of traditional Medicare, you place decisions about your health in the hands of an insurance company intent on making a profit. Three-quarters of the Medicare Advantage business is currently in the hands of six huge insurers: Humana, CVS, Anthem, Kaiser Permanente, Centene, and Cigna.
Because of the “potential incentive for Medicare Advantage Organizations to deny beneficiary access to services and deny payments to providers in an attempt to increase profits,” the Health & Human Services agency inspector general just reviewed the performance of Medicare Advantage insurers. The results were not good.
Of the prior approval requests that Medicare Advantage insurers denied, 13% should have been approved. Of the payment denials by Medicare Advantage insurers, 18% were improper under both the rules of Medicare and the Medicare Advantage insurer’s own rules. Some improper decisions were reversed by the Medicare Advantage insurer, but that often happened only after “a beneficiary or provider appealed or disputed the denial.”
The three causes of these improper denials:
• Using clinical criteria that Medicare does not apply
• Requesting unnecessary documentation
• Errors in the insurer’s manual review or system
Since every improper denial is a money saver for the insurance company, you have to wonder how intentional this rate of impropriety is.
Since every improper denial is a hardship to a patient and/or medical provider, you have to wonder how the government can allow this kind of behavior.