Medicare | Managed Care | Sean Brown

FAH Calls for Enhanced Oversight of Medicare Advantage Plans to Stop Abuses

This morning the House Energy and Commerce Committee Oversight and Investigations Subcommittee held a hearing entitled, “Protecting America’s Seniors: Oversight of Private Sector Medicare Advantage Plans.”

Before the proceedings began, FAH submitted a letter for the record highlighting concerns over abuses by some Medicare Advantage (MA) plans that deny access to necessary patient care and have inadequate care networks.

The letter states, “MA plans systemically apply problematic operating policies, procedures and protocols” to limit patients access to care. “FAH urges Congress to examine and address MA plan abuses more broadly to promote beneficiary access to timely and appropriate care.”

FAH reiterated the key points from a recent HHS OIG report that identified a pattern by which MA plans apply utilization controls to improperly withhold coverage or care from patients. Specifically:

• Improper prior authorization denials
• Improper denials for lack of documentation
• Improper payment request denials

FAH asked CMS to take broad steps to protect beneficiaries from these MA plan abuses, including reviewing:

• Network adequacy
• Access to post-acute care
• Risk adjustment claim encounter submissions
• Use of third-party contractors to perform audits
• Appeal rights

You can read the complete FAH letter here.