Congressional legislators are casting doubts on regulatory oversight of Medicare Advantage (MA) plans over concerns about spending, claims denials and end-of-life care.
Several lawmakers expressed these reservations during a House Energy and Commerce Committee’s Oversight and Investigation subcommittee hearing that focused on the MA program.
“Improper claim denials and increased use of prior authorizations are preventing beneficiaries from receiving the care they need,” Energy and Commerce Chairman Frank Pallone, Jr. (D-N.J.) said during the hearing. “While there are many plans that appear to be acting responsibly, some are not, and these bad actors are costing taxpayers money and, more importantly, jeopardizing the health of seniors.”
Officials from several federal agencies testified, including the U.S. Department of Health & Human Services Office of the Inspector General (OIG), the Medicare Payment Advisory Commission (MedPAC), and the Government Accountability Office.
No representatives from the U.S. Centers for Medicare & Medicaid Services (CMS) or any MA plans spoke at this hearing. Pallone indicated that the subcommittee’s investigation would continue, so those stakeholders could appear in future hearings.
Assistant HHS Inspector General Erin Bliss raised concerns during the hearing about MA plans using chart reviews or in-home health risk assessments to diagnose patients, often without additional follow-up. Payments related to those assessments cost Medicare $2.6 billion in 2017 alone, she indicated.
Her testimony referenced a recent OIG report on that issue.
While the report said that CMS agreed with an OIG recommendation that they strengthen oversight of plans with high rates of risk-adjusted payments tied to those assessments, to date the agency has not done so.
Bliss also testified under oath that plans inappropriately delayed or denied treatment for some beneficiaries and that CMS guidance on denials may be insufficient.
MedPAC’s June 2022 report to Congress included similar findings, according to the commission’s executive director, James E. Mathews, who appeared before the subcommittee.
Some proponents of the program, including the Better Medicare Alliance (BMA), have questioned those findings. The alliance is an advocacy group whose members include insurance companies and other health care stakeholders.
“Better Medicare Alliance appreciates the Commission’s acknowledgment that risk adjustment in Medicare Advantage ‘has largely been successful in serving its general purpose,’” BMA President and CEO Mary Beth Donahue said in a statement on the MedPAC report. “We and our partners across the Medicare Advantage community have long been committed to stable and accurate risk adjustment policies.”
Some lawmakers also questioned in the hearing whether CMS had sufficient staff or budget to address these issues.
Subcommittee chairwoman Diana DeGette (D-Colo.) also said that she would like to know why a higher proportion of Medicare Advantage beneficiaries disenrolled during the last year of life.
One potential factor is that historically MA does not cover hospice care. Those beneficiaries who elect hospice typically transition to the Medicare Hospice Benefit.
While those patients are not required to leave MA, many do. However, further analysis is needed to determine how many of the beneficiaries who disenrolled in their last year also elected hospice.
In the coming years, MA may play a larger role in the hospice space, as evidenced by the value-based insurance design model demonstration (VBID).
Often called the Medicare Advantage hospice carve-in, the VBID demonstration project took effect on Jan. 1, 2021. The carve-in is designed to assess payer and provider performance related to hospice within Medicare Advantage.
MA as a whole is rapidly growing. More than 28 million beneficiaries are enrolled in MA for 2022, representing about 45% of all Medicare recipients, according to research by Chartis Health. This reflects a total enrollment increase of 9% over 2021.
Chartis projects that MA will account for 50% of all Medicare beneficiaries by 2025.
Despite the oversight concerns, a number of Congress members who spoke at the hearing spoke positively about the MA program itself.
“The Medicare Advantage program is an important tool for seniors, and we all want to see it succeed,” DeGette said at the hearing. “We will continue to conduct the oversight necessary to ensure that plans are providing beneficiaries with the quality care that they deserve and that taxpayer dollars are being appropriately spent on delivering health care to our valuable seniors.”
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