Inspector General: Some Medicare Advantage Plans Deny Services

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Inspector General: Some Medicare Advantage Plans Deny Services

Anew study by the U.S. Health & Human Services Department Office of Inspector General found Second, Medicare Advantage organizations indicated that some prior authorization requests did not have some Medicare Advantage plans denied or delayed patients’ access to care even though the requests for services were medically necessary and met Medicare coverage rules.

The patients likely would have received approval if they had been enrolled in traditional Medicare rather than Medicare Advantage, according to Rosemary Bartholomew, an analyst in the HHS-OIG San Francisco office.

Bartholomew says these denials can delay and prevent patient access to needed care, cause patient to pay out of pocket for services that are supposed to be covered by their plan, and cause burdens for patients (and providers) who choose to go through the appeal process.

Medicare Advantage plans are based on “capitation payments,” which means the physician, clinic or hospital receives a fixed pre-arranged payments per month per patient enrolled — in other words, per capita. The amount does not change, regardless of the cost of services. This has the advantage of lowering the cost for the plan.

A central concern about the capitated payment model used in Medicare Advantage is the potential incentive for Medicare Advantage organizations to deny beneficiary access to services and deny payments to providers in an attempt to increase profits.

Although Medicare Advantage organizations approve the vast majority of requests for services and payment, they issue millions of denials each year, and Medicare annual audits of Medicare Advantage organizations have highlighted widespread and persistent problems related to inappropriate denials of services and payment.

As Medicare Advantage enrollment continues to grow, Medicare Advantage organizations play an increasingly critical role in ensuring that Medicare beneficiaries have access to medically necessary covered services and that providers are reimbursed appropriately.

Here is the staff report on the study:

Method

Staff selected a stratified random sample of 250 prior authorization Medicare fee-for-service). We identified two common causes denials and 250 payment denials issued by 15 of the largest Medicare Advantage organizations during June 1-7, 2019. Health care coding experts conducted case file reviews of all cases, and physician reviewers examined medical records for a subset of cases. From these results, staff estimated the rates at which Medicare Advantage organizations denied prior authorization and payment requests and the types of services associated with these denials in our sample.

Findings

Case file reviews determined that Medicare Advantage organizations determine whether Medicare Advantage organizations may deny authorization Medicare Advantage organization’s system was not programmed or updated sometimes delayed or denied Medicare Advantage beneficiaries’ access to services, even though the requests met Medicare coverage rules. Medicare Advantage organizations also denied payments to providers for some services that met both Medicare coverage rules and Medicare Advantage organizations billing rules. Denied requests that meet Medicare coverage rules may prevent or delay beneficiaries from receiving medically necessary care and can burden providers. Although some denials we reviewed were ultimately reversed by the Medicare Advantage organizations, avoidable delays and extra steps create friction in the program and may create an administrative burden for beneficiaries, providers, and Medicare Advantage organizations. Examples of health care services involved in denials that met Medicare coverage rules included advanced imaging (such as MRIs) and inpatient rehabilitation after discharge from an acute-care facility. Prior authorization requests. We found that, among the prior authorization requests that Medicare Advantage organizations denied, 13 percent met Medicare coverage rules; in other words, these services likely would have been approved for these beneficiaries under original Medicare (also known as of these denials. First, Medicare Advantage organizations used clinical criteria that are not contained in Medicare coverage rules (such as requiring an x-ray before approving more advanced imaging), which led them to deny requests for services that our physician reviewers determined were medically necessary. Although our review determined that the requests in these cases did meet Medicare coverage rules, Medicare guidance is not sufficiently detailed to based on internal Medicare Advantage organizations’ clinical criteria that go beyond Medicare coverage rules. enough documentation to support approval, yet our reviewers found that the existing beneficiary medical records were sufficient to support medical necessity of the services. Payment requests. We found that, among the payment requests that Medicare Advantage organizations denied, 18 percent of the requests met Medicare coverage rules and Medicare Advantage organizations’ billing rules. Most of these payment denials in our sample were caused by human error during manual claims processing reviews (such as overlooking a document) and system processing errors (such as the correctly).

“Service Denial” page 10

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Medicare Advantage plans are based on “capitation payments,” which means the physician, clinic or hospital receives a fixed pre-arranged payments per month per patient enrolled — in other words, per capita.

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“COVID Update” from page 7

The Justice Department appealed at the CDC’s request but the agency did not ask for a stay, which would have reinstated the mandate.

U.S. District Judge Kathryn Kimball Mizelle ruled in favor of Health Freedom Defense Fund and airline travelers Ana Carolina Daza and Sarah Pope, who claimed the CDC failed to provide a 30-day comment public period required for new regulations.

Mizzell provided a 59-page explanation, based on the Public Health Services Act of 1944, which specifies sanitation as a measure that could be necessary to prevent disease from spreading, but has no definition of sanitation.

“Wearing a mask cleans nothing,” the judge wrote. “At most it traps virus droplets. But it neither ‘sanitizes’ the person wearing the mask nor ‘sanitizes’ the conveyance.”

The government interprets “sanitation” to mean “applying of measures for preserving and promoting public health.” The judge disagreed, writing that historically, public health has been regulated at the state level, and the 1944 law has no clear language that Congress intended the CDC to take over.

The CDC did not allow public comment although the Administrative Procedures Act requires agencies provide a 30-day comment period on new rules.

The CDC did not explain mask exemptions for people eating, drinking or taking medication or for children under age 2. By not explaining, the CDC action was arbitrary and capricious, the judge ruled.

After ordering masks, the CDC did not conduct a study to generate scientific evidence that wearing cloth masks slows spread on an airplane.

The CDC’s Covid-19 map shows most counties green for low transmission. New York State, Vermont and Connecticut all have high transmission. Santa Cruz County and neighboring Santa Clara County are medium.

Santa Cruz County, which updates its dashboard on Monday and Thursday, reports 1,379 active cases, on the rise but down from the peak of 10,000.

Omicron Less Deadly

The Omicron variants are less deadly than the Delta variant, which raged in 2021.

Santa Cruz County reported 37 Covid deaths after Omicron, compared to 225 as of Dec. 15, before Omicron.

One statistic is similar: 79% to 81% of those who died had pre-existing conditions.

Why do people fear Omnicron?

They may have a pre-existing condition (diabetes, obesity, asthma, high blood pressure).

Half of Americans do, so they are at higher risk for severe Covid illness.

So are people 85 and older.

California reports 83.3% of residents age 5 and up have had at least one shot.

On the CDC Covid tracker, Santa Cruz County reports 90.8% of residents age 5 and up have at least one shot and 82.9% fully vaccinated.

Pajaro Valley Schools

The Pajaro Valley Unified School District reports 92 active student cases and 19 staff cases in May. Aptos High has 18 student cases and 2 staff cases. Aptos Junior High has 10 student cases and one staff case. Valencia Elementary has 8 student cases and 1 staff cases. Rio del Mar Elementary has 6 student cases and zero staff cases. Mar Vista Elementary has 1 student case and 1 staff case.

The state guidance to schools and childcares as of March 11. Masks are not required but strongly recommended.

Santa Cruz County Office of Education, with Inspire Diagnostics, has provided 472,100 tests.

Cases in local schools peaked at 4,407 on Jan. 27, dropped to 44 on April 1, then rose to 455 on May 11. The 14-day positivity rate, 12.25% on January, dropped to .79%, then rose to 3.16%.

Fully vaccinated means having two shots (Pfizer or Moderna) or one Johnson & Johnson shot. All were developed for the initial Wuhan Covid-19 strain.

For Omicron, a booster shot is needed after the Pfizer vaccine, because protection against hospitalization wanes after three months, a Kaiser Permanente study of 11,000 hospital admissions and emergency room visits found.

Vaccine Database

In a 2022 report in the Journal of American Medical Association online, Dr. Matthew Oster of the CDC reported the government’s VAERS database received 1,991 reports of myocarditis after one dose of mRNAbased Covid-19 vaccine and 1,626 met the CDC’s definition for probable or confirmed myocarditis.

Oster’s conclusion: “The risk of myocarditis after receiving mRNA-based Covid-19 vaccines was increased across multiple age and sex strata and was highest after the second vaccination dose in adolescent males and young men. This risk should be considered.”

The 2022 NFL Scouting Combine changed its COVID-19 policies after agents representing more than 150 draft prospects began organizing a boycott of testing, workouts and interviews at the event in response to the league’s bubble restrictions, according to a memo obtained by The Athletic.

The changes allowed players to leave the bubble during free time or have approved medical personnel, athletic trainers and massage therapists join them in secure areas.

Public health officials say the scientific consensus is that Covid vaccines are safe, but some are skeptical about relying on science from drug-makers, which saw profits rise in 2021. They point to the U.S. government database, https://vaers.hhs. gov/, where health care providers are to report adverse events after a vaccine.

The reporting site was created after Congress passed a law in 1986 protecting vaccine manufacturers from civil personal injury lawsuits and wrongful death lawsuits resulting from vaccine injuries.

Health and Human Services Secretary Alex Azar invoked the Public Readiness and Emergency Preparedness Act, a 2005 law allowing him to provide legal protection to companies making or distributing critical medical supplies such as vaccines unless there’s “willful misconduct” by the company. This protection lasts until 2024.

Renz Law, representing military whistleblowers, sued the federal government to lift the vaccine mandate for military personnel and appeals for passage of legislation repealing immunity for vaccine manufacturers.

“If vaccines are truly safe and effective no one should oppose this,” the lawsuit reads.

After mRNA COVID-19 vaccines were mandated for the military in 2021, cases of heart attack, pulmonary embolism, cancers, and myocarditis spiked dramatically, according to the Defense Military Epidemiological Database queries by the whistleblowers.

The Department of Defense’s response was that a glitch in the database affected the data from 2016-2020.

Myocarditis is inflammation of the heart, which can lead to clots, a stroke or heart attack.

Dr. Pamela Popper, whose group supported the lawsuit, posts updates at https://makeamericansfreeagain.com/

Testing

The Santa Cruz County Office of Education offers drive-though testing for students, staff and families at:

Cabrillo College, Aptos, Parking Lot K, Monday to Friday 9 a.m. to 5 p.m. and Saturday 9 a.m. to 3 p.m.

Santa Cruz County Office of Education, 399 Encinal St., Santa Cruz, Monday to Friday, 9 to 5 p.m. Saturday, 9 a.m. to 3 p.m.

See: https://tinyurl.com/ get-tested-santa-cruz.

Booster shots: https://myturn. ca.gov/

Vaccine providers: www.santacruzhealth.org/coronavirusvaccine.

Local information: www.santacruzhealth.org/coronavirus or (831) 454-4242 from 8 a.m. to 5 p.m. Monday through Friday. n

••• Total COVID cases: 1,379

••• COVID Deaths: 262 As of May 12 Age 85 and older: 113 • 75-84: 61 65-74: 46 • 60-64: 15 • 55-59: 4 45-54: 10 • 35-44: 8 25-34: 5 Underlying Conditions Yes: 212 • No: 50 Race White 150 • Latinx 89 • Asian 16 Black 3 • Amer Indian 1 Hawaiian 1 • Another 2 Gender Men: 135 • Women: 127 Location At facility for aged: 116 Not at a facility: 146

“Service Denial” from page 9

We also found that Medicare Advantage organizations reversed some of the denied prior authorization and payment requests that met Medicare coverage and Medicare Advantage organization billing rules.

Often the reversals occurred when a beneficiary or provider appealed or disputed the denial, and in some cases Medicare Advantage organizations identified their own errors.

Recommendations

Our findings about the causes and circumstances under which Medicare Advantage organizations denied prior authorization or payment for requests that met Medicare coverage and Medicare Advantage organization billing rules provide an opportunity for improvement to ensure that Medicare Advantage beneficiaries have timely access to all necessary health care services, and that providers are paid appropriately. Therefore, we recommend that Medicare: • issue new guidance on the appropriate use of Medicare Advantage organization clinical criteria in medical necessity reviews; • update its audit protocols to address the issues identified in this report, such as Medicare Advantage organization use of clinical criteria and/or examining particular service types; and • direct Medicare Advantage organizations to take additional steps to identify and address vulnerabilities that can lead to manual review errors and system errors. n