During hearings on health care affordability, members of the House Energy and Commerce Committee Subcommittee on Health and House Committee on Ways and Means zeroed in on Medicare Advantage, questioning insurance executives about prior authorization practices, hospital coverage disputes, alleged overbilling of the federal government, and the impact of consolidation on rural access.
CEOs from UnitedHealth Group, CVS Health, Elevance Health, The Cigna Group, and Ascendium/Blue Shield of California on Thursday testified at both hearings. While the broader hearings covered affordability across all health insurance markets, Medicare Advantage emerged as one of the most scrutinized areas.
Legislators raised concerns that while Medicare Advantage is popular, it may be undermining access and driving up federal spending through aggressive utilization management and questionable coding practices.
Prior authorization
One of the most persistent bipartisan concerns centered on prior authorization, the process Medicare Advantage use to determine whether a service will be covered.
Rep. Kim Schrier (D‑Wash.), a physician, described a Medicare Advantage enrollee who suffered a stroke and required hospitalization, but whose UnitedHealth Medicare Advantage plan refused initial payment, deeming the stay “medically unnecessary,” despite the treating physician’s determination that the patient was not safe to go home. The appeal took more than a year.
Schrier called the case “unconscionable,” noting that elderly patients recovering from major medical events are often in no position to fight with their insurer.
UnitedHealth Group CEO Stephen Hemsley, who represents the insurer with the largest Medicare Advantage market, bore the brunt of much of the questioning during the hearings. He responded that he was not familiar with the case but agreed that stroke patients “should get all the care that's appropriate for them.”
Rep. Buddy Carter (R‑Ga.), a pharmacist, described a breast‑cancer patient whose UnitedHealth Medicare Advantage plan denied medications recommended by her oncologist even though the treatments were meant to reduce the risk of recurrence. He pressed Hemsley on why a plan would override specialist recommendations. Hemsley pledged to follow up on the case.
Other lawmakers cited cases where Medicare Advantage plans denied imaging, specialty drugs, or follow‑up care. The denials were later overturned but only after delays that could worsen health outcomes, they said.
Schrier pointed to data showing 80 percent of appeals of Medicare Advantage denials are ultimately overturned. She argued that such statistics create the appearance that insurers rely on wearing patients down, denying care upfront knowing many seniors will not have the capacity to challenge the decision.
In-home assessment diagnoses
House representatives from both parties expressed concern about federal oversight reports showing that some Medicare Advantage organizations use in‑home assessments or chart reviews to add diagnoses to patient records, which can increase federal payments even when those diagnoses are not actively managed.
Rep. Mariannette Miller‑Meeks (R‑Iowa), a former state health director and physician, said that that “congestive heart failure is not a paperwork diagnosis,” questioning why insurers would rely on home assessments to add conditions while denying provider claims due to insufficient documentation.
Oversight findings by the Department of Health and Human Services’ Office of Inspector General revealed that Medicare Advantage plans often add diagnoses that drive payments but may not reflect clinically managed disease, she said. The CEOs defended their risk‑adjustment practices but agreed that reforms to documentation standards and oversight would be appropriate.
Access concerns
Rep. Jay Obernolte (R‑Calif.) pressed Hemsley on reports that some critical access hospitals in rural California are no longer in‑network under certain Medicare Advantage plans, forcing seniors to drive hours for care. He warned that excluding rural hospitals from networks puts financially fragile facilities at risk of closure and leaves seniors without accessible care options.
Hemsley acknowledged “meaningful pressure” on Medicare Advantage plan finances due to recent federal payment changes and said UnitedHealth is piloting expedited payment programs to strengthen rural provider participation.
Vertical integration
Several lawmakers expressed concern that large insurers own medical groups, pharmacy benefit managers pharmacies, and other entities. Rep. Diana Harshbarger (R‑Tenn.) highlighted data showing that insurers’ vertically integrated structures allow companies to control “coverage, pricing, dispensing, and care decisions,” raising fears that Medicare Advantage enrollees are being steered to corporate-owned providers and pharmacies.
The CEOs testified that integration allows for better care coordination, lower drug prices, and improved member experiences.
The benefits of Medicare Advantage
Despite criticism, all CEOs strongly defended the program.
- Hemsley described Medicare Advantage as offering lower total costs than traditional Medicare while providing more benefits and “lower overall cost to seniors,” adding that seniors show a consistent preference for Medicare Advantage.
- Cigna CEO David Cordani emphasized Medicare Advantage’s ability to coordinate medical, pharmacy, and behavioral care, calling it essential for improving outcomes for beneficiaries with chronic conditions.
- Several CEOs underscored that insurer margins in Medicare Advantage are slim, and that rising medical and drug costs—not insurer behavior—drive much of the program’s spending growth.
However, the CEOs agreed improvements are needed, including streamlining prior authorization, strengthening transparency, and focusing more on preventive and value‑based care.