A group of bipartisan senators urge the Centers for Medicare & Medicaid Services (CMS) to close data gaps to strengthen oversight of Medicare Advantage plans (MA) and improve care for Medicare beneficiaries.
U.S. Senators Bill Cassidy, M.D. (R-La.), Elizabeth Warren (D-Mass.), Marsha Blackburn (R-Tenn.), and Catherine Cortez Masto (D-Nev.) this week wrote a letter to CMS Administrator Chiquita Brooks-LaSure, raising concerns about the findings of federal watchdogs that have found shortfalls in CMS’ data collection and reporting practices for MA plans.
They specifically cited audits by the Department of Health and Human services Office of Inspector General (HHS OIG) about inappropriate prior authorization denials and billions in overpayments reported by the Medicare Payment Advisory Commission.
“These findings raise important questions about ensuring the integrity and fiscal sustainability of the Medicare Advantage program,” they wrote. “Without publicly available plan-level data on prior authorization requests by type of service, timeliness of determinations and reasons for denials; claims and payment requests denied after a service has been provided; beneficiary out-of-pocket spending; and disenrollment patterns, policymakers and regulators are unable to adequately oversee the program and legislate potential reforms.”
The senators urged CMS to collect and publish the following data:
- Prior authorization requests, denials, and appeals by type of service. CMS does not collect these data by type of service, by beneficiary characteristic and health status, or by plan. As a result, they said, researchers, regulators, and lawmakers cannot evaluate whether prior authorization requests, denials, and appeals are more common for certain types of services or patients, or whether MA insurers are complying with CMS requirements to cover all Medicare Part A and Part B services.
- Justification of prior authorization denials. Without explanation, CMS and regulators are limited in their ability to assess whether prior authorization requests were appropriately denied.
- Timeliness of prior authorization decisions. Collecting this data would help researchers track which services take longer than others to receive prior authorization and allow beneficiaries to compare prior authorization response times across plans when selecting coverage.
- Complete encounter data. Encounter data is often incomplete, which makes it difficult to track plan performance.
- Utilization of supplemental benefits and associated out-of-pocket costs. There is little information publicly available on enrollees’ utilization of these benefits, the specific items or services they receive, or associated out-of-pocket spending. These extra benefits are popular with seniors and utilization data would allow CMS to better assess their quality and value.
In addition, the senators want CMS to publicly release the following data that it is already collecting:
- Out-of-pocket costs and provider payment information. Publicly available MA encounter data does not include any information on provider payments or out-of-pocket liability for beneficiaries. CMS should validate and publish this information in line with existing regulations, to ensure that researchers, lawmakers, and beneficiaries can better understand cost-sharing structures across MA plan offerings.
- Disaggregated disenrollment data. Publishing these data would allow researchers to evaluate whether certain groups disenroll from MA at higher rates than others and whether disenrollment rates are associated with out-of-pocket costs or coverage denials.
- Plan comparison information. CMS is required to publish a comparison between quality and performance indicators in MA and traditional Medicare, including information on health outcomes. CMS should ensure this information is up to date and easily accessible on the CMS website to assist seniors in comparing the benefits of MA and traditional Medicare.
The senators have asked CMS to provide a staff-level briefing on its plan to improve its data collection and reporting practices for MA plans by December 27.