RISE rounds up recent headlines that impact the Medicare Advantage industry.

AHA calls for False Claims Act investigation into MA improper denials

The American Hospital Association last week urged the Department of Justice to create a task force to conduct False Claims Act investigations into health insurers that routinely deny patients access to services and deny payments to health care providers.

The letter comes in the wake of an Office of Inspector General report last month that found Medicare Advantage (MA) Organizations sometimes delayed or denied MA beneficiaries’ access to services even when the requests met Medicare coverage rules. The report was based on a random sample of 250 prior authorization denials and 250 payment denials issued by 15 of the larges MAOs during the one-week period of June 1-7, 2019. It found 13 percent of the prior authorization denials and 18 percent of payment denials should have been granted.

RELATED: OIG report on prior authorizations raises concerns about MA beneficiary access to medically necessary care

“These harmful denials all occurred in a single week. Imagine what else the Justice Department might find if it conducted a more far-reaching investigation,” the AHA asked in the letter. The recommendations in the report are sensible but they aren’t enough, according to the organization.

“It is time for the Department of Justice to exercise its False Claims Act authority to both punish those MAOs that have denied Medicare beneficiaries and their providers their rightful coverage and to deter future misdeeds,” the AHA said. “This problem has grown so large and has lasted for so long that only the prospect of civil and criminal penalties can adequately prevent the widespread fraud certain MAOs are perpetrating against sick and elderly patients across the country, as well as against the public fisc every time commercial insurers take $1,000 per beneficiary while denying medically-necessary services.”

The AHA urged the Justice Department to create a “Medicare Advantage Fraud Task Force” to investigate the denials.

But Bill Horton, a partner at law firm Jones Walker, told Modern Healthcare that the False Claims Act may not be the right enforcement tool for MA prior authorization denials. There is danger, he said, in using the False Claims Act against differences in medical opinion or interpretation of unclear regulations and policies.

AMA also weighs in on prior authorization process

A physician survey conducted in December 2021 and recently released by the American Medical Association (AMA) said that the health insurer industry has failed to follow through on prior authorization reforms agreed to in 2018. The survey examined the experiences of more than 1,000 practicing physicians with each of the five prior authorization reforms in the consensus statement.

Waiting on a health plan to authorize necessary medical treatment is too often a hazard to patient health,” AMA President Gerald E. Harmon, M.D., said in a statement. “Authorization controls that do not prioritize patient access to timely, optimal care can lead to serious adverse consequences for waiting patients, such as a hospitalization, disability, or death. Comprehensive reform is needed now to stem the heavy toll that continues to mount without effective action.”

The survey found:

  • Fewer than one out of 10 physicians said they contracted with health plans that offer programs that selectively apply prior authorization requirements.
  • Eighty-four percent reported the number of drugs and the number of medical services requiring prior authorization has increased.
  • Nearly two-thirds of physicians reported it was difficult to determine whether a drug requires prior authorization and 62 percent found it difficult to determine whether a medical service requires prior authorization.
  • Eighty-eight percent reported that prior authorization interferes with continuity of care.

BMA endorses legislation to modernize prior authorization for seniors

Better Medicare Alliance on Thursday endorsed H.R. 3173, the Improving Seniors’ Timely Access to Care Act.

The bipartisan legislation, sponsored by Reps. Suzan DelBene (D-WA), Mike Kelly (R-PA), Ami Bera, M.D. (D-CA), and Larry Bucshon, M.D. (R-IN), would modernize the way MA uses prior authorization as a clinical tool to coordinate beneficiaries’ care.

“The Improving Seniors’ Timely Access to Care Act is a commonsense solution that builds on the work the Medicare Advantage community has been doing to streamline prior authorization for seniors. With Medicare Advantage already delivering nearly $2,000 in annual savings to consumers and lower per-beneficiary spending for taxpayers, this is another way that Medicare Advantage can continue to raise the bar in the delivery of affordable, accessible coverage and care," Mary Beth Donahue, president and CEO of the Better Medicare Alliance, said in the announcement. "We are pleased to support this bipartisan measure and look forward to working with CMS, the provider community, and other stakeholders to facilitate a smooth adoption and transition to electronic prior authorization protocols.”

Study: 100,000 older Americans got unnecessary surgeries during first year of COVID-19

A recent analysis by the Lown Institute, a health care think tank, found that hospitals in the United States performed more than 100,000 unnecessary and potentially harmful procedures on older patients between March and December 2020. The most performed unnecessary procedures? Coronary stents and back surgeries.

Analysts used data from the 100 percent Medicare claims database from January to December 2020 to evaluate volume of overuse for eight common low-value procedures. The overuse criteria were based on the Lown Institutes previously published research into measurement of low-value care at hospitals. The latest analysis shows that thousands of patients were admitted to U.S. hospitals during the height of the pandemic, before COVID-19 vaccines were approved, for procedures that offer little to no clinical benefit or were more likely to harm patients than help them.

“You couldn’t go into your local coffee shop, but hospitals brought people in for all kinds of unnecessary procedures,” Vikas Saini, M.D., president of the Lown Institute, said in an announcement about the study. “The fact that a pandemic barely slowed things down shows just how deeply entrenched overuse is in American health care.”

Other key takeaways from the report:

  • Of the 100,000 procedures, 45,000 were unnecessary coronary stents and 30,000 were unnecessary back surgeries.
  • From June to December 2020, with no vaccines available to vulnerable older adults, hospitals delivered low-value services to Medicare patients at rates similar to 2019.
  • All the hospitals on the US News Honor Roll ranking had rates of coronary stent overuse higher than the national average in 2020 and four had rates at least twice that.