Retirees may face this hassle with Medicare Advantage, survey finds

Retirees may face this hassle with Medicare Advantage, survey finds:

According to a recent research, seniors who choose private Medicare insurance plans shouldn’t be afraid to challenge pre-authorization denials.

According to a recent research from the nonprofit Kaiser Family Foundation (KFF), two million of the 35 million prior authorization requests made by Medicare Advantage members for medical services or drugs in 2021 were totally or partially refused.

However, the survey found that of the 11% of instances that were disputed, insurers overturned more than 82% of their initial judgements.

The findings indicate that seniors may wish to take more time comparing prices for these common services, raising concerns that the approval procedure may put unneeded impediments in the way of patients receiving medical treatment.

“The high frequency of good results following appeal raises doubts about whether a bigger percentage of original findings should have been accepted,” wrote Nolan Sroczynski, a data analyst for KFF, and Jeannie Fuglesten Biniek, associate director of the programme on Medicare Policy at KFF.

It can be a result of original requests that lacked the required supporting paperwork. In either scenario, the additional step of appealing the first prior authorization decision may have had an adverse impact on beneficiaries’ health since medical care that was recommended by a healthcare professional and subsequently determined to be required was possibly delayed,” the authors said.

People who are enrolled in Medicare Advantage plans, a for-profit, managed-care alternative to conventional Medicare, are particularly affected by the pre-authorization hoops.

99% of Medicare Advantage members in 2022 were covered by a plan that needed prior permission for some treatments. According to the KFF analysis, which examined data from 515 Medicare Advantage contracts, representing 23 million Medicare Advantage members, higher cost procedures like chemotherapy or stays in skilled nursing facilities are more frequently subject to prior authorization.

Insurance coverage requiring prior authorization has been a thing for a very long time. It’s a tactic insurers use to control expenses by ostensibly making sure no one is getting treated for treatments and services that are not medically required.

According to Biniek of Yahoo Finance, “Insurers utilise pre-authorization differently.” “I was

For instance, the researchers discovered that the denial rate varied from 3% for Anthem and Humana to 12% for CVS (Aetna) and Kaiser Permanente. For CVS (20%) and Cigna (19%), the proportion of denials that were challenged was nearly twice as high as the national average (11%). The percentage of Kaiser Permanente denials that were challenged was far smaller (1%).

To be clear, just a small portion (380,000) of the surgeries and services approved after patients pushed back were fully funded. For instance, a prior authorization request may have asked for 10 therapy sessions, but only five would have been granted, according to the study’s findings.

However, Biniek noted that “those who go through that appeals procedure are generally successful.” “We don’t know if that’s because the appellants have the option to appeal, butbest case to make, but there may be more opportunity there for people to have some of these requests ultimately approved.”

Medicare Advantage vs traditional Medicare

The main draw of Medicare Advantage plans is that they typically offer some coverage for items not included in conventional Medicare, such as eyeglasses, dental coverage, and fitness courses, but traditional Medicare seldom needs prior authorization for healthcare services or medications.

According to The Commonwealth Fund’s 2022 Biennial Health Insurance Survey of 1,605 persons enrolled in Medicare, around one in four (24%) Medicare beneficiaries noted the additional advantages of a Medicare Advantage plan when making their decision to join in a particular plan. Twenty percent of respondents (or 1 in 5) also cited a cap on out-of-pocket expenses as the primary factor in their decision.

When deciding on Medicare Advantage, consumers often make significant trade-offs, according to Biniek.

But many do. Out of the 58.6 million total Medicare beneficiaries last year, 28.4 million (or 48% of those who were eligible for Medicare) were enrolled in Medicare Advantage programmes.

Medicare Advantage shoppers need to ask about the pre-authorization policy

Therefore, Biniek advised seniors wishing to enrol in Medicare Advantage plans to compare the standards of various Medicare Advantage plans in order to assist avoid the hassle of appealing refused pre-authorizations.

The Centers for Medicare and Medicaid Services (CMS) requires these insurers to submit data for each Medicare Advantage contract that includes the number of prior authorization determinations made during a year and whether the request was approved. This is part of its oversight of Medicare Advantage plans. The number of initial judgements that were appealed as well as the results of that procedure must also be disclosed by insurers.

According to Philip Moeller, a Medicare and Social Security expert and the lead author of the “Get What’s Yours” series of books about Social Security, Medicare, and health care, “The Kaiser report does not include reasons for denials, but other studies have shown that missing paperwork and errors in medical coding are common.” Moeller made this statement to Yahoo Finance.

The report’s omission of information on rejections is due to: According to the researchers, Medicare Advantage insurers are not obliged to state in the reporting to the CMS the reason a refusal was made, such as whether the treatment was not judged medically essential, inadequate documentation was supplied, or other standards for coverage were not satisfied.

Leave a Comment