Sen. Warren pushes for more data on Medicare Advantage coverage hurdles, denials

A bipartisan group of senators is urging the Biden administration to beef up the amount of data it collects from private Medicare plans in order to combat overpayments and improper care denials.

Sen. Elizabeth Warren (D-Mass.) and three of her colleagues sent a letter Thursday to Medicare administrator Chiquita Brooks-LaSure that asked her to dramatically expand the amount of data her agency collects and publicly reports from Medicare Advantage plans, especially when it comes to prior authorizations, claim denials, and coverage of supplemental benefits. This year marks the first time half of Medicare members are enrolled in MA, but those plans routinely refuse to cover necessary services. In order to adequately oversee the program and create reforms, the lawmakers say they need more granular plan-level data.

“[Medicare] can collect and publish these data using its existing authority,” the senators wrote. “To strengthen the transparency of MA plans and improve care for Medicare beneficiaries, we urge [Medicare] to take these actions.”

The letter, also signed by Sens. Bill Cassidy (R-La.), Marsha Blackburn (R-Tenn.), and Catherine Cortez Masto (D-Nev.), asks the agency to share its plan for collecting the data by Dec. 27.

First up on the lawmakers’ wish list is more data on requests for prior authorization, which is when insurers require advance approval before covering certain services. While insurers claim this is done to cut unnecessary spending, the lawmakers said it’s a burden on providers and can delay necessary care.

Specifically, the letter asks Medicare to collect and report prior authorizations by plan, type of service, and characteristics of the members involved. The agency already reports the total number of prior authorizations across all MA plans, whether they were approved or denied, and appeal outcomes. But without that additional information, the letter said researchers, regulators, and lawmakers can’t study whether those hurdles are more common with certain services or members.

The lawmakers also want the agency to collect and report the reasons for claim denials. Without that, they said stakeholders can’t assess whether the denials were appropriate. They also asked for the number of denials broken out by plan instead of in aggregate, as it’s currently collected.

This is happening in an era of heightened scrutiny around MA plans, which will soon be subject to more federal audits that will likely force them to repay billions of dollars in overpayments. The audit rule, although watered down from its original version, is meant to scrutinize whether plans have made their members appear sicker to get more money from the government.

Just last month, a group of House Democrats sent their own letter to Medicare demanding better oversight. They cited a recent STAT investigation that found insurance companies use artificial intelligence and algorithmic software to deny necessary care. About a week later, STAT reported that UnitedHealth Group pressured employees to use an algorithm to issue MA denials.

Right now, plans don’t have to report how long it takes them to approve prior authorization requests, and the lawmakers said Medicare ought to collect and report that as well. Their letter doesn’t specify whether they should use averages or lists of requests. They also asked the agency to report how often the plans requested extra time to consider the requests.

Although MA plans already have to report data on patient encounters, including what services were provided and patients’ health conditions, they don’t have to say which services they didn’t cover. The letter wants plans to include denied-claim indicators in their encounter data so they’re easier to track.

Almost all MA plans entice members using supplemental benefits like dental, hearing, and vision, which aren’t available under traditional Medicare. However, the lawmakers noted there’s little data on how much members use those benefits. They want Medicare to collect and report that utilization along with the specific services they’re getting and members’ associated out-of-pocket costs.

“Medicare Advantage plans hype extra benefits pretty aggressively, and these extras attract seniors, but Medicare does not track how often these extra benefits are being used, how much people are paying for them, or how and whether use varies across plans,” Tricia Neuman, the executive director of KFF’s Program on Medicare Policy, wrote in an email.

The senators also asked Medicare to publicly release several data sets that it already collects. That includes data on how much MA members pay out-of-pocket and how much the plans pay medical providers. One perk of MA over traditional Medicare is that the plans must cap members’ out-of-pocket spending, but they wrote it’s important that researchers, lawmakers, and members can make sure the plans are complying.

The letter also asked the agency to report the number of people who drop out of MA, broken down by plan. Not only that, but also the characteristics of the members who disenroll, including their race, ethnicity, age, and care setting. Making this data public would help researchers determine whether certain groups disenroll at higher rates than others, the letter said.

Finally, the letter asked to ensure information that compares quality and performance of MA plans to traditional Medicare is up-to-date and easily accessible on Medicare’s website.

Asked for comment, Medicare said only that it had received the letter and planned to respond. The country’s two largest MA insurers, UnitedHealthcare and Humana, did not respond to a request for comment, nor did health insurers’ biggest lobbying group, America’s Health Insurance Plans.

Neuman said collecting and publishing basic information like denial rates by plan and type of service will “help to fill a blind spot by giving Medicare more tools for program oversight and giving beneficiaries better information to make important decisions about their coverage.”