They often denied medically necessary care to beneficiaries and payments to doctors that met Medicare coverage rules.  OIG found that 13% of prior authorization requests that were denied met Medicare coverage rules, as did 18% of physician payment requests that were turned down.

In response to the report, American Medical Association President Gerald E. Harmon, MD, said the findings “mirror physician experiences.”  “Surveys of physicians have consistently found that excessive authorization controls required by health insurers are persistently responsible for serious harm when necessary medical care is delayed, denied, or disrupted,” he said.

Advantage plans also refused to pay legitimate claims, according to the report. About 18 percent of payments were denied despite meeting Medicare coverage rules, an estimated 1.5 million payments for all of 2019. In some cases, plans ignored prior authorizations or other documentation necessary to support the payment.

Consider this case.  Kurt Pauker, an 87-year-old Holocaust survivor in Indianapolis who has kidney and heart conditions that complicate his care, is enrolled in a Medicare Advantage plan sold by Humana.  In spite of recommendations from Mr. Pauker’s doctors, his family said, Humana has repeatedly denied authorization for inpatient rehabilitation after hospitalization, saying at times he was too healthy and at times too ill to benefit.

joelshirschhorn Seniors Are Getting Suckered Into Medicare Advantage Plans