Medicare Advantage Plans Criticized for Denying Necessary Care

Reports Reveal Issues with Medicare Advantage

Recent analyses by U.S. investigators indicate concerning practices within Medicare Advantage plans, particularly regarding the denial of requests for short-term nursing home or inpatient rehab services.

“Two reports found that major insurers denied about 13 percent of patients’ requests,” summarized a key finding.

Challenges for Enrollees

Many people enrolled in private Medicare Advantage plans, which serve around 35 million older Americans, face inappropriate refusals for skilled nursing care post-hospital discharge. These plans, integrated within the federal Medicare program, have previously faced scrutiny over their hesitancy to provide necessary medical services.

Prior authorization acts as a hurdle, requiring insurers to approve treatment before patients receive care. This system benefits insurers financially as they receive a fixed sum per patient, motivating them to minimize expenses on treatments.

Reports from Federal Investigators

An in-depth analysis from the Department of Health and Human Services inspector general targeted major insurers like UnitedHealth Group, Humana, and CVS Health. These companies collectively cover a significant portion of the Medicare Advantage enrollees.

Findings show that 13 percent of patient requests for skilled nursing facilities following surgery or severe illness were denied. Concerns extend to whether the insurers’ contractors responsible for authorizing specialized care are under sufficient oversight.

Rosemary Bartholomew, leading the government’s review, emphasized, “The dominance of a few large insurance companies in Medicare Advantage means that their policies can significantly impact millions of people.”