AHA calls for task force to investigate payment denials
The association cited a recent report showing that 18% of payment denials actually met Medicare Advantage coverage rules and should have been granted.
The American Hospital Association on Thursday asked the U.S. Department of Justice to establish a ”Medicare Advantage Fraud Task Force” to conduct False Claims Act investigations into commercial health insurance companies that are found to routinely deny patients access to services and deny payments to health care providers.
The association, in a letter to the department, cited a recent report showing that 13% of prior authorizations and 18% of payment denials actually met Medicare Advantage coverage rules and should have been granted.
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“In a program the size of Medicare Advantage — with 26.4 million beneficiaries, or 42% of the total Medicare population in 2021 — improper denials at this rate are unacceptable,” the letter said. “Yet, as the report explained, because the government pays Medicare Advantage Organizations a roughly $1,000 per-beneficiary capitation rate, they have every incentive to deny services to patients or payments to providers in order to boost their own profits.”
The letter illustrated the human impact of these denials, including a 72-year-old woman with a cancerous breast tumor who was denied reconstruction surgery; a 67-year-old patient denied admittance to an inpatient rehabilitation facility following a stroke; and an MAO that refused to pay $150 a month for a hospital bed with rails, even though a 93-year-old patient had a history of epilepsy, early-onset Alzheimer’s, rheumatoid arthritis, chronic back pain, knee and joint stiffness, and limited range of motion.
“These harmful denials all occurred in a single week,” the letter said. “Imagine what else the Justice Department might find if it conducted a more far-reaching investigation. It is time for the Department of Justice to exercise its False Claims Act authority to both punish those MAOs that have denied Medicare beneficiaries and their providers their rightful coverage and to deter future misdeeds.
“This problem has grown so large — and has lasted for so long — that only the prospect of civil and criminal penalties can adequately prevent the widespread fraud certain MAOs are perpetrating against sick and elderly patients across the country, as well as against the public treasury every time commercial insurers take $1,000 per beneficiary while denying medically necessary services.”
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