In a report published on Thursday, federal investigators concluded that tens of thousands of people are denied necessary care every year because they are in private Medicare Advantage plans.
The investigators urged Medicare officials to strengthen oversight of private insurance plans which provide benefits to 28 million older Americans and called for increased enforcement against plans with a pattern of inappropriate denials.
Advantage plans offer privatized versions of Medicare that are frequently less expensive and provide a wider array of benefits than the traditional government-run program.
Half of Medicare beneficiaries are expected to choose a private insurer over the traditional government program in the next few years, as the number of people choosing Advantage plans has more than doubled over the last decade.
The industry's main trade group claims people choose Medicare Advantage because it delivers better services, better access to care and better value.
The inspector general's office of the Health and Human Services Department looked into whether some of the services that were rejected would have been approved if the beneficiaries had been in traditional Medicare.
Tens of millions of denials are issued each year for both authorization and reimbursements, and audits of the private insurers show evidence of widespread and persistent problems related to inappropriate denials of services and payment.
The report shows that private plans were reversing about three-quarters of their denials on appeal. Congress is considering legislation to address some of the concerns of hospitals and doctors about the insurance company tactics.
According to the inspector general's office, there were repeated examples of care denials for medical services that coding experts and doctors reviewing the cases determined were medically necessary and should be covered.
The investigators estimated that as many as 85,000 beneficiary requests for prior authorization of medical care were potentially wrongly denied in 2019.
According to the report, Advantage plans refused to pay legitimate claims. About 18 percent of payments were denied because they didn't meet Medicare coverage rules. In some cases, plans ignored prior authorizations.
Rosemary Bartholomew, who led the team that worked on the report, said that these denials may delay or even prevent a Medicare Advantage beneficiary from getting needed care. She said that only a small percentage of patients or providers try to appeal.
She said that they are concerned that beneficiaries may not be aware of the barriers.
Kurt Pauker, an 87-year-old Holocaust survivor in Indianapolis who has a variety of health conditions, is using a Medicare Advantage plan sold by Humana.
Mr. Pauker's family said that Humana denied authorization for rehabilitation at times because he was too sick or healthy to benefit.
After undergoing hip surgery, Mr. Pauker was told that he would have to go back to a skilled nursing center to recuperate.
The family said that he received little in the way of physical or occupational therapy during his previous stay. He has lost his appeals and relatives have decided to pay for his care privately.
David B. Honig is a health care lawyer and Mr. Pauker's son-in-law. He said that people who sign up for Medicare Advantage are giving up their right to have a doctor decide what is medically necessary.
Humana said it couldn't comment on Mr. Pauker's case because of privacy rules. The insurer said it had to follow the standards set by the Centers for Medicare and Medicaid Services.
We work to provide health coverage that is consistent with what C.M.S. would require in each instance and supports our members in achieving their best health.
Medicare officials said in a statement that they are reviewing the findings to determine the appropriate next steps and that plans found to have repeated violations will be subject to increasing penalties.
The agency is committed to ensuring that people with Medicare Advantage have timely access to medically necessary care.
Private insurers are paid a fixed amount by the federal government. If the patient's choice of hospital or doctor is limited and he or she is encouraged to get services that are less expensive but effective, the insurer stands to profit.
Hospitals and doctors may over treat patients if they are paid for each service and test they perform. The report concluded that the fixed payment given to private plans gave insurers the incentive to deny access to services in order to increase their profits.
The president-elect of the American Medical Association said the plans had become widespread. Lawmakers have been lobbying to impose stricter rules.
Dr. Resneck said that prior authorization has spread way beyond its original purpose. Many patients don't fill prescriptions when they can't get approval for a new one, he said.
Some doctors said that appeals end up burdening patients and taking too much time.
We are able to reverse this some of the time, according to Dr. Kashyap Patel, who is the chief executive of Carolina Blood and Cancer Care and the president of the Community Oncology Alliance. He said that his efforts to get approvals for the care he recommends leave him less time to tend to patients.
The investigators found that the most frequent denials were for services like M.R.I. An Advantage plan refused to approve a follow-up M.R.I. to determine if a small lesion was cancer after it was identified through an earlierCT Scan because it was too small. After an appeal, the plan reversed its decision.
A patient had to wait five weeks for authorization to get aCT Scan to assess her cancer and to determine a course of treatment. Delayed care can affect a patient's health.
Advantage plans denied requests to send patients to a skilled nursing center or rehabilitation center when the doctors decided that those places were more appropriate than sending a patient home.
The patient was denied a transfer to a skilled nursing center because he had bedsores and a skin infection. A high-risk patient recovering from surgery to repair a fractured femur was denied admission to a rehab center, although doctors said the patient needed to be under the supervision of a physician.
In some cases, the investigators said Medicare rules needed to be clarified.
The plans can use their own clinical criteria to decide whether a test or service should be paid for, but they have to offer the same benefits as traditional Medicare and can't be more restrictive in paying for care.
The investigators urged Medicare officials to beef up oversight of Advantage plans and give consumers clear, easily accessible information about serious violations.
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