More oversight needed for Medicare Advantage plans, General Accountability Office says

The federal government needs to increase its oversight over private Medicare health plans to make sure seniors have adequate access to doctors and hospitals, according to a report released this week by congressional auditors.

The General Accountability Office study found the Centers for Medicare & Medicaid Services, which administers Medicare Advantage plans, primarily relies on complaints from consumers to determine if they are having trouble getting appointments with providers.

The government reviews less than 1 percent of the information filed annually by provider networks for adequacy and accuracy. It looks only at the networks of plans entering new markets and not at those in existing markets, the GAO said.

The congressional watchdog also found that the government approves more than 90 percent of requests from health plans for exemptions from federal rules on network adequacy, which determine how far a consumer has to go to find a doctor.

About 16 million seniors are in Medicare Advantage plans, 30 percent of the Medicare population. Unlike traditional Medicare which allows consumers to see any provider, those in Medicare Advantage must see a doctor or facility in the plan's network. Medicare Advantage enrollees are locked into their health plan for a year.

[Also: CMS signals tight controls in first class of value-based Medicare Advantage participants]

The GAO report was spurred by concerns from patient advocates that Medicare health plans don't provide members enough choices of doctors and certain specialists, and that health plan provider directories often inaccurately list doctors who no longer accept the coverage.

In 2013, UnitedHealthcare, the nation's largest Medicare Advantage plan, dropped thousands of doctors in Connecticut and nine other states from their Medicare networks. That drew complaints from seniors who had signed up for plans largely because they wanted access to certain providers.

"This investigation shows what I have long said: Medicare Advantage patients have no recourse to stop bad behavior like we saw in Connecticut with UnitedHealth," said Rep. Rosa DeLauro, D-Conn., who requested the GAO report.

Joe Baker, president of the Medicare Rights Center in New York, said his nonprofit group often gets calls from seniors who are upset that provider directories from their Medicare plans list doctors who don't take their health plan.  He said the report suggests that CMS can improve its enforcement.

"CMS needs to do a better job to make sure these networks are accessible and that providers are available," Baker said.

CMS officials told GAO investigators they are stepping up their audits of Medicare Advantage provider networks, the report said.  A CMS spokesman said plans typically are exempted from network adequacy rules when few doctors are available to contract with or when consumers can easily go to an adjoining county for care.

The rules for ensuring consumers have access to care vary by type of provider and county population density. For example, in large counties, CMS requires members to have a choice of primary care providers within 5 miles of their home or a 10-minute drive, the report said.

Health plans in recent years have reduced the number of providers to control costs and focus on those who provide better service and care.

"Medicare Advantage plans are under same pressure as all health plans to contain costs and to reward their highest value providers and this probably is resulting in some network narrowing," said Michael Adelberg, a senior director with FaegreBD Consulting in Washington.

But Adelberg said health plans need to keep consumers abreast when doctors drop out of their plans. "Consumers have a right to know what they are buying," he said.

Like Healthcare Finance on Facebook

Judith Stein, executive director of the Center for Medicare Advocacy, said the report shows the government must better monitor health plans.  Her organization is pushing for a bill to be reintroduced in Congress that would require health plans to notify members if providers are terminated from their networks. Though seniors each year can change health plans or choose traditional Medicare, most stay in the same plans year after year, she said.

The center's bill would also prohibit Medicare Advantage Plans from dropping providers during the middle of the year and require that plans finalize their provider networks 60 days before the annual enrollment period begins. That period this year runs from Oct. 15 to Dec. 7.

Allyson Schwartz, president of the Better Medicare Alliance, which represents Medicare Advantage plans, said the industry is committed to making sure provider networks meet the needs of seniors.

"It is important that CMS continue to work with Medicare Advantage plans to provide transparency, accountability and timely information on provider networks and beneficiary access to the critical care that many seniors need," Schwartz said in a statement.

Kaiser Health News is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Twitter: @HC_Finance