Audits Show Ongoing Errors in Medicare Advantage, Part D Plans
Federal officials have found numerous and varied errors with Medicare Advantage plans, including improper claims denials and baseless coverage limits on prescription drugs, according to several federal audit reports, the New York Times reports.
Medicare's open enrollment period launches Wednesday and will last until Dec. 7. According to the Times, millions of U.S. residents are preparing to sign up for the program. Currently, about 16 million of the 54 million Medicare beneficiaries, or about 30%, are enrolled in MA plans. Meanwhile, 23 million additional beneficiaries are enrolled in prescription drug coverage.
Medicare Coverage Issues
According to the Times, federal officials repeatedly have expressed concern over various coverage deficiencies in MA plans. Specifically, Gerard Mulcahy, director of Medicare Parts C and D Oversight and Enforcement Group, identified common "areas of noncompliance" that were detailed in federal audit reports.
For example, Medicare officials have levied civil penalties and have taken other enforcement actions regarding practices that could harm Medicare patients by denying or delaying access to care. According to the Times, insurers typically do not dispute such audit results. However, the insurers have said that the coverage they provide to patients is better than that offered on traditional fee-for-service Medicare.
Meanwhile, CMS has reported that:
- "[B]eneficiaries and providers did not receive an adequate or accurate rationale for the denial" of claims in more than 50% of all audits;
- Insurers often did not consider clinical data submitted by health care providers when making claims decisions and did not let beneficiaries know about their rights to appeal claims decisions;
- Insurers "inappropriately rejected claims" for prescriptions medications, enforced "unapproved quantity limits" and mandated that beneficiaries receive permission before filling prescription drugs when such "prior authorization" was not permitted in 61% of audits; and
- Medicare coverage plans often missed deadlines for making claims decisions regarding health care, drugs and medical dives requested by both providers and beneficiaries.
Further, the documents listed insurers that have been penalized for the violations, including:
- Arizona, Florida and North Carolina-based Blue Cross and Blue Shield companies;
- CalOptima in California;
- Capital BlueCross and Geisinger Health Plan in Pennsylvania.
- Health Alliance Plan in Michigan;
- Moda Health in Oregon;
- Tufts Health Plan in Massachusetts; and
- WellCare Health Plans in Florida.
Insurance consultant and former Medicare official John Gorman said, "It's unforgivable that so many [MA] plans are still struggling with basic compliance issues." He said that companies that insurers hired to oversee their prescription drug plans "know how to manage drug benefits for working-age people with commercial insurance, but they are confounded by the complex needs of seniors. Many are failing Medicare beneficiaries" (Pear, New York Times, 10/12).
Enrollment in High-Rated MA Plans Increasing
Meanwhile, CMS officials on Friday announced that the number of people enrolled in high-rated MA plans or individual prescription drug plans is increasing, CQ HealthBeat reports.
According to CQ HealthBeat, CMS rates such health plans on a quality scale of one to five, with five being the highest rating a plan can receive. For the 2015 coverage year, the number of plans rated with four or more stars grew by 6% for MA plans and by 36% for Medicare Part D prescription plans over 2014. Meanwhile, about 60% of current MA beneficiaries are enrolled in plans rated with four or more stars for 2015, up from about 17% in 2009. For Medicare Part D plans, 53% of enrollees have plans rated with four or more stars for 2015, up from 16% in 2009 (Adams, CQ HealthBeat, 10/10).This is part of the California Healthline Daily Edition, a summary of health policy coverage from major news organizations. Sign up for an email subscription.