Medicare Advantage, the prior authorization scam

Preface

Medicare Advantage exists only because the federal government tells you the Big Lie in economics that federal taxes fund federal spending.

They don’t. Federal taxes fund nothing.

Federal taxes are destroyed upon receipt by the Treasury. Federal spending is funded by new dollar creation.

The purposes of federal taxes are not to fund federal spending but to:

1. Control the economy by taxing what the government wishes to discourage and giving tax breaks to what the government wishes to reward.
2. Increase demand for the U.S. dollar by requiring taxes to be paid in dollars.
3. Widen the Gap between the rich and the rest by convincing those who are not wealthy that giving them benefits requires raising taxes, a lie.

Let us examine an article About Medicare Advantage:

Enrollment in Medicare’s private-sector alternative is surging — and so are the complaints to Congress.

BY DAVID LIM AND ADAM CANCRYN | AUGUST 23, 2023

More than 30 million older Americans are enrolled in Medicare Advantage plans, wooed by lower premiums and more benefits than traditional Medicare offers.

Since Medicare is funded by the federal government (not by FICA taxes), how is Medicare Advantage able to “woo” people with lower premiums and more benefits? What is their secret to saving?

But a bipartisan group of lawmakers is increasingly concerned that insurance companies are preying on seniors and, in some cases, denying care that would otherwise be approved by traditional Medicare.

Is this a surprise? Preying on seniors and denying care is the whole point of Medicare Advantage. The government created the program to reward the rich.

Any thinking person could predict that a private, for-profit program, competing with a government not-for-profit program, would have to deny services and fool customers. How else can they make a profit while taking business from the government program?

“It was stunning how many times senators on both sides of the aisle kept linking constituent problems with denying authorizations for care,” Sen. Ron Wyden (D-Ore.) said in an interview, referring to a bevy of complaints from colleagues during a recent Senate Finance Committee hearing.

Businesses are strongly motivated to deny authorizations for the most expensive procedures, the exact procedures for which people most need insurance. Prior authorization is a notorious scam.

Congress has already gone after insurers for their celebrity-filled ads and misleading directories. But its scrutiny of these care denials, expected to continue into next year, could have a far greater impact and reshape the rules for one of the most profitable parts of the insurance industry.

The private health insurance industry cannot survive without prior authorization or some other process that skims away their highest costs.

“CMS is very attuned to what is going on on the Hill,” Sean Creighton, managing director of policy for consulting firm Avalere Health, said of the Centers for Medicare and Medicaid Services. He added that next year will likely bring “more scrutiny by the Hill and CMS on this, and there will be more reporting requirements for the plans and actions the plans are required to take to lessen the burden on providers and patients.”

Yes, “more scrutiny and more reporting requirements” — anything to avoid doing what really should be done: Eliminate FICA and offer federally funded, comprehensive, no-deductible, no-copay Medicare for every man, woman, and child in America.

The federal government could pay for the whole thing by tapping a computer key, and it could do it without the need to supervise private insurance services.

The hugely profitable private healthcare insurers, who bribe Congress,  would object.

And, of course, the rich who run America don’t want it, because it would narrow the income/wealth/power Gap between the rich and the rest of us. Keeping the poorer poor is how the rich stay rich. That is what the rich bribe Congress to do.

Legislation requiring insurers to more quickly approve requests for routine care passed unanimously in the House in 2022, but stalled in the Senate over cost concerns.

Federal “cost concerns” are unnecessary.

Because the federal government is Monetarily Sovereign, cost never should be a primary consideration.

The government can pay for anything. In fact, the more the government pays, the more the economy grows.

The Improving Seniors’ Timely Access to Care Act, which mandates insurers quickly approve requests for routine care and respond within 24 hours to any urgent request, was reintroduced this year in the House and passed out of the House Ways and Means Committee this summer as part of a larger health care package.

Still, lawmakers are peppering the Biden administration with demands for reforming the commonly used tool called prior authorization, the process in which health insurers require patients to get insurer approval ahead of time for certain treatments or medications.

Without prior authorization, Medicare Advantage would have no price “advantage,” and scant ability to compete with Medicare.

It “has turned into a process of basically just stopping people from getting care,” said Rep. Pramila Jayapal (D-Wash.), leader of the House Progressive Caucus.

Stopping people from getting care — i.e. stopping health insurers from paying big bills — is the point. Imagine a car insurer demanding that people get prior authorization before starting the car, and then denying any long or more risky drives.

Jayapal was one of more than three dozen House Democrats who told CMS this month of “a concerning rise in prior authorizations,” accused health insurers of prioritizing “profits over people” and asked for “a robust method of enforcement to rein in this behavior.”

Oh, really” A business that prioritizes profits? Who could have predicted that? There would be no need to “rein in this behavior” if the federal government funded health care.

Unlike traditional Medicare, Medicare Advantage plans can employ prior authorization and restrict beneficiaries to certain doctors within their network. Those are among the incentives private insurers have to participate in the program and enrollment has doubled during the last decade.

But Sen. James Lankford (R-Okla.) said some hospitals in his state won’t take Medicare Advantage plans any more. “We can’t do it because we can’t afford the constant chasing from all the denials,” he said.

AHIP, the trade group representing insurers, told POLITICO that prior authorization was among the tools that can curb wasteful spending.

Prior authorization has very little to do with wasteful spending and everything to do with cutting big costs. If a doctor, who knows a patient, authorizes a procedure, and some lowly insurance company employee, who never met the patient refuses to pay for the doctor-authorized procedure, how does that prevent “wasteful spending?

“These tools are important when coordinating care, reducing unnecessary and low-value care, and promoting affordability for patients and consumers,” said spokesperson David Allen in a statement.

Utter nonsense. It’s double-talk for “the less we pay, the more we make.”

CMS has a track record of responding to liberal concerns, which could translate into big changes for Medicare Advantage in the coming years. Earlier this month, it proposed a rule to improve the standards for behavioral health networks following complaints from Congress about woefully inaccurate mental health provider directories, which some lawmakers said amounted to fraud.

It also for the first time this year is evaluating Medicare Advantage television ads before they air, following prodding from lawmakers and numerous complaints from elderly consumers who felt duped by the ubiquitous ads.

Interesting that Medicare Advantage can provide “more benefits” at “lower prices,” and still afford all that television advertising, reap profits, and even pay taxes — and compete with Medicare. Do you believe in magic? Where does all the extra money come from? Service refusal.

CMS also proposed a rule earlier this month that plans be required to factor the impact of prior authorization denials on marginalized and underserved communities, part of a larger effort by the agency to close gaps in health equity. The rule, if finalized, would take effect in 2025.

You can be sure that the insurance companies will find a way around that one. Service denial is the bedrock of Medicare Advantage.  Without service denial, the program could not exist.

Sen. Elizabeth Warren (D-Mass.), who wants the agency to go further, has proposed an amendment that would require CMS to collect and publish data from Medicare Advantage plans on their prior authorization practices to make public the number of prior authorization requests, denials and appeals by type of medical care.

She has support from Sen. Mike Crapo (R-Idaho), who said during a recent hearing that his support for Medicare Advantage plans “does not mean that I like the prior authorization process and that I do not see some problems here that need to be solved.”

Original Medicare does not require prior authorization. Congress could outlaw the whole prior authorization, service denial scam, but that would end Medicare Advantage and all those wonderful profits, along with all those wonderful political bribes.

Insurer advocacy group Better Medicare Alliance told POLITICO it supports legislation and regulations to create an electronic prior authorization process that could expedite prior authorization decisions that typically take up to a week or more.

No, expediting a failed process doesn’t make it a good process. The whole process says, “We know more than your doctor about your health needs” and/or “Your doctor is crooked, so we’ll have one of our flunkies make your healthcare decisions.”

“Our goal has always been to protect prior authorization’s essential function — coordinating safe, effective, high-value care— while also strengthening and streamlining this clinical tool to better serve beneficiaries,” Mary Beth Donahue, president and CEO of the group, said in a statement.

Pardon me if I laugh, but does anyone believe the purpose of prior authorization is to “coordinate safe, effective, high-value care, while strengthening blah, blah, blah”? The purpose of prior authorization is to save money via service denial. Period.

BY DAVID LIM AND ADAM CANCRYN | AUGUST 23, 2023 
Creighton suspects insurers would be fine with implementing guardrails for prior authorization, as long as they can continue to use it.

“It is super important that in this case one doesn’t throw out the prior authorization with the bath water,” he said. “It is just finding that balance.”

No, that is exactly what should be done: Throw out prior authorization. It’s an invitation to cheating helpless, sick patients stuck with big bills or no service.

But many physicians complain that balance has tipped too far in favor of Medicare Advantage plans.

A survey released earlier this month by the physicians’ trade group Medical Group Management Association found 97 percent of medical group practices said an insurer delayed or denied medically necessary care.

Another 92 percent said they had hired staff specifically to process prior authorization requests. A December 2022 survey from the American Medical Association also found that 94 percent of physicians reported care delays due to prior authorization denials or processing.

“Even when you are doing the most cost-effective treatment, you are going through the [prior authorization] process,” said Vivek Kavadi, chief radiation oncology officer for U.S. Oncology, a network of more than 1,200 physicians.

Studies show that oncology faces the most prior approval requests.

“I’m sorry Mrs. Jones, but we can’t operate on your cancer until we get prior authorization. It could take weeks, while your cancer grows and metastasizes. Or the procedure could be denied in which case you’ll be on the hook for $50,000 which will bankrupt you and your family. Or maybe, you’ll just die. Which do you choose?”

Five oncologists told POLITICO that prior authorization requests are increasing as more patients migrate from traditional Medicare to Medicare Advantage. This surge of insurer prior approval demands has put a strain on their practices’ resources, they said.

The people who migrate tend to be the ones who least can afford to pay for denied procedures. As usual, the rich have found a way to cheat the middle and the poor.

Insurers may at times contract with radiation benefit managers, companies that manage claims processing and keep a cut of savings they generate.

This can encourage more services requiring prior authorization and create a “greater incentive to identify opportunities where denials can be pushed on to the provider,” said Constantine Mantz, chief policy officer for the oncology network GenesisCare.

If you pay people to deny services, they will deny services.

EviCore, a radiation benefit manager, said its work is meant to ensure patients receive care grounded in the latest clinical evidence as quickly as possible. “For requests that don’t meet evidence-based guidelines, the [physician] has the opportunity to discuss the case … which can help resolve any concerns prior to initiating a formal appeal,” the company said in a statement.

So, the goal is to prevent a doctor from prescribing an unnecessary procedure, and this will be cleared up when the doctor discusses the case with a “benefit manager”?  Really?

BMA did not wish to comment and AHIP declined to respond to a list of questions on radiation benefit managers.

Medicare Advantage plans have been slow to update their coverage policies and at times lag Medicare in which treatments are covered, Mantz said. This can lead to situations where a Medicare Advantage plan denies care after a prior authorization request that would be covered under traditional Medicare.

Of course. What other outcome could there be? The whole purpose of prior approval is to deny payment.

BY ALICE MIRANDA OLLSTEIN AND LAUREN GARDNER | OCTOBER 05, 2023 05:00 AM
HHS’ Office of the Inspector General in a 2022 report found 13 percent out of a sample of claims from Medicare Advantage plans in which care was denied under prior authorization for services that should have been approved.

You can be sure the 13 percent figure is low, but even if were accurate, would you go to a hospital knowing there was a 13 percent chance your legitimate procedure would not be covered? I wouldn’t.

If a request is denied, a doctor can file an appeal and eventually speak with another physician to plead their case.

This is exactly what you don’t want your doctor spending his valuable time doing: Pleading his case to another doctor who has not seen you and doesn’t even know you.

Recent studies have shown that most appeals to a denial get overturned. In 2021, Medicare Advantage plans fully or partially denied more than 2 million claims through prior authorization, but 82 percent of those were overturned after an appeal, according to an analysis from the think tank KFF.

A 2019 survey from ASTRO found 62 percent of oncologists, who appealed on behalf of their patients, got their prior authorization denial overturned.

If the vast majority of denials are overturned,  something clearly is wrong with the denial process. It would be informative to know why denials are overturned. What are the circumstances that cause all those “bad” denials and their cancellation.

Apparently, those denials were unnecessary, and when the doctors caught the insurance companies with their hands in the cookie jar, the denials were reversed. The insurance companies seemingly tell their people, “Deny everything you can, but if a doctor objects, reverse the denial. Just make the process as tedious as possible.”

But doctors say getting through the appeals process can take weeks.

“It feels more like the business model is a way for insurance companies to potentially reduce costs by feeling that physicians won’t want to participate in this peer-to-peer process because it is a burden on time,” said Amar Rewari, chief of radiation oncology for the Maryland-based health system Luminis Health.Mei

The insurance companies increase profits by making the process difficult for patients and doctors. This is the opposite of what one would expect from a health service.

SUMMARY

No public purpose is served by transferring the cost of health care to the private sector, where profitability requirements can supersede healthcare needs. Though cutting prices is a selling strategy, it is a poor tradeoff for bad service.

Innocent consumers, lured in by lower prices and coverages not offered by Original Medicare, too often find themselves uninsured at just the times when they need help most, with bankruptcy-causing bills or not receiving medical care at all.

The federal government already had proved its capability of funding healthcare services with Original Medicare. a relatively no-hassle service.

Unnecessarily, Medicare saves money by not paying for everything. There are co-pays, deductibles, and some services not covered. But the federal government, being Monetarily Sovereign, does not need to save money. It has infinite dollars.

The federal government is financially capable of providing comprehensive, all-inclusive, no-copay, no-deductible Medicare to every man woman and child in America, without collecting a penny in taxes.

The purpose of government is to improve and protect the lives of the people. The U.S. government, having unlimited financial capability, and already having the experience funding medical care, should carry out its mandate.