Lawmakers press UnitedHealthcare, Aetna, Humana on Medicare Advantage claims denials

Lawmakers are seeking more information about claims denials from the largest Medicare Advantage insurers. 

On May 17, the Senate Permanent Subcommittee on Investigations sent letters to CVS Health, Humana and UnitedHealth Group seeking internal documents detailing how the companies decide to approve or deny claims, including how the payers use artificial intelligence in the process. 

"I want to put these companies on notice. If you deny lifesaving coverage to seniors, we're watching, we will expose you, we will demand better, we will pass legislation if necessary," subcommittee Chair Sen. Richard Blumenthal said in a news release. 

Around 13 percent of prior authorization claims denials in Medicare Advantage were for services that met Medicare coverage rules, Megan Tinker, chief of staff for HHS' Office of Inspector General, told the subcommittee May 17. 

These denials likely delayed or prevented Medicare Advantage beneficiaries from receiving needed care, she said. 

CMS is implementing new rules aimed at curtailing the use of prior authorization in Medicare Advantage. 

Ms. Tinker told the subcommittee the OIG needs more resources to fully investigate claims denials in Medicare Advantage. The agency is turning down 300 to 400 viable healthcare fraud cases each year because of a lack of sufficient staff, she said in her testimony. 

"Despite extensive reviews and enforcement, our limited resources do not allow us to provide comprehensive oversight of Medicare and Medicaid," Ms. Tinker said. "Notwithstanding rigorous efforts by OIG and support from Congress, the administration and HHS for OIG work and resources, serious fraud, waste, and abuse continue to threaten HHS programs and the people they serve." 

Sen. Ron Johnson, a member of the subcommittee, said the prior authorization process can be improved by reintroducing "consumerism and free market competition into healthcare." 

"Under a third-party payment system, everyone wants the best quality treatment and couldn't care less what it costs. That is what is driving our healthcare costs through the roof," Mr. Johnson said at the May 17 hearing. "Pre-approval programs for some treatments and tests are the third-party payer's attempt to limit wasteful spending." 

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