Survey shows 13% of Medicare Advantage enrollees had a claim or pre-authorization request denied

Photo: Reza Estakhrian/Getty Images

A spotlight has been put on Medicare Advantage denials for claims and pre-authorizations following the release of an Office of the Inspector General report that found MA plans denied requests that met original Medicare coverage rules.

An eHealth survey of more than 2,800 Medicare beneficiaries, conducted in May 2022, found that 13% of Medicare Advantage enrollees had a claim or pre-authorization request denied. Those who experienced a self-reported denial of coverage included many who were declined for benefits, such as dental and vision care, which Medicare usually doesn't cover.

However, 15% of those who had a claim or pre-authorization request initially denied said it was eventually paid by their insurer, according to eHealth, a health insurer provider.

Bob Rees, eHealth's VP of Medicare sales, said it's important not to lean too heavily on the 13% figure, for a couple reasons.
 
"First, this includes both claims and pre-authorization requests," he said. "Second, this is self-reported data, and what some consumers may consider a 'denial' isn't always a denial in the technical sense."
 
For example, coverage restrictions based on provider networks, drug formulary rules and even Medicare's own coverage guidelines may be included in these self-reported denials.
 
"When it comes to denials, I think the more telling figures from our report include the fact that 3% say they were denied coverage for a specific prescription drug, 2% were denied coverage for visits with specific doctors, and less than 1% were denied coverage for inpatient hospital care," Rees said.
 
From his perspective, it's hard to see MA plans denying prior authorizations that meet Medicare approval as a major concern when overall satisfaction with MA is so high among enrollees, as reflected in the survey.
 
Rees added that the overall high level of satisfaction with MA means that the astronomical growth in Medicare Advantage enrollment is likely to continue.
 
"As reported elsewhere, a strong majority of Medicare beneficiaries love their coverage across the board, regardless of their personal Medicare configuration," he said. "It's no different within Medicare Advantage. The low premiums and convenience of Medicare Advantage all but ensure that its growth and popularity will continue."
 
WHY THIS MATTERS

Medicare Advantage Organizations (MAOs) sometimes delayed or denied Medicare Advantage beneficiaries' access to services, even though the prior authorization requests met Medicare coverage rules, according to the April OIG report.

MAOs indicated that some prior authorization requests did not have enough documentation to support approval, yet OIG reviewers found that the beneficiary medical records already in the case file were sufficient to support the medical necessity of the services.
 
THE LARGER TREND

Enrollment in MA plans, which are offered by private insurance companies, has more than doubled since 2011, totaling more than 29 million in 2022, according to the Centers for Medicare and Medicaid Services.

Enrollment is projected to continue to grow, along with insurers' participation in the lucrative program.

These plans typically fill the coverage gaps in Medicare as well as offer additional benefits, and most also include Part D prescription drug coverage.

The MA plans have the additional benefit of being more affordable than Medicare Supplement and stand-alone Part D plans, with many beneficiaries able to enroll in $0-premium Medicare Advantage plans.
 
ON THE RECORD

"We found that a striking majority of Medicare Advantage enrollees are satisfied with their plans," the report noted. "Many find in it precisely the affordable, comprehensive, all-in-one coverage they value and need. In fact, most feel that Medicare Advantage offers a commendable example of cooperation between government and private enterprise."
 

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