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As scrutiny on Medicare Advantage grows, a bipartisan group of four senators sent a letter to the Centers for Medicare and Medicaid Services (CMS) last week asking the agency to collect and publish more data on MA plans. This includes data on prior authorization practices.
The four senators that signed the letter were Elizabeth Warren (D-Massachusetts), Catherine Cortez Masto (D-Nevada), Bill Cassidy (R-Louisiana) and Marsha Blackburn (R-Tennessee). The letter was addressed to CMS Administrator Chiquita Brooks-LaSure.
The letter highlighted several stats that raise questions about Medicare Advantage practices. For instance, in 2019, only 13% of MA prior authorization denials and 18% of MA payment denials met Medicare coverage rules, according to the Office of the Inspector General. This shows that MA plans “delayed or denied seniors access to services that would have likely been approved under traditional Medicare,” the senators stated. In addition, researchers have found that between 2010 and 2019, CMS gave MA plans $106 billion in excess payments. In just 2023, MA plans are expected to receive $27 billion in overpayments, according to MedPAC.
“These findings raise important questions about ensuring the integrity and fiscal sustainability of the Medicare Advantage program,” the senators said.
To help Congress better understand the MA program, the senators made several requests of CMS, including the collection and publishing of data on prior authorization requests, denials, and appeals by type of service. CMS already reports aggregated data on the total number of prior authorization requests sent by MA plans, if they were approved or denied and the outcome of appeals. However, the agency does not have this data separated out by type of service, by beneficiary health status or by plan.
“As a result, 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,” the senators argued.
The letter also calls for CMS to collect and publish data on the reasons behind prior authorization denials. Further, the legislators want to know how long it takes to complete prior authorization requests.
In addition, there is some data that CMS is collecting that the senators would like to see publicly released. This includes information on out-of-pocket costs and provider payments.
“Beneficiaries like MA products because, unlike [traditional Medicare], MA plans are required to cap out-of-pocket spending,” the letter states. “MA plans must also use any rebates to either lower beneficiary cost-sharing or offer supplemental benefits. But 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.”
The senators urged CMS to publish more detailed information on why seniors choose to disenroll from MA and enroll in traditional Medicare, as well as more up-to-date information that compares the quality and performance of MA versus traditional Medicare.
They asked CMS to provide a briefing on how the agency plans to advance its MA data collection and reporting practices by December 27.
Photo: designer491, Getty Images
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