Federal health officials are proposing a broader set of tougher rule It administers a private Medicare Advantage health plan in response to widespread complaints that too many patients’ medical claims have been falsely denied and the plan’s marketing is deceptive.
Medicare Advantage is a private sector alternative to federal programs that cover people over 65 and people with disabilities. By next year more than half of Medicare beneficiaries are expected to be enrolled in private plans. These policies are often less expensive than traditional Medicare and may also offer attractive additional benefits such as dental care.
Despite its popularity, the scheme has recently been the subject of considerable scrutiny and criticism. report The inspector general for the U.S. Department of Health and Human Services has found that some plans may be inappropriately denying care to patients. In addition, nearly all of the major insurers participating in the program, including UnitedHealth Group, Elevance Health, Kaiser Permanente and Cigna, have been sued by the Department of Justice for fraudulently overcharging the government.
Widespread criticism of the deceptive tactics some brokers and insurers have used to lure people into changing plans has been amplified in the period leading up to this year’s registration deadline of December 7. In November, Senate Democrats issued a scathing statement report It details some of the worst practices, including ads that appear to represent federal agencies and ubiquitous TV commercials featuring celebrities.
Federal Medicare officials have said they will review television ads before they air, but the new rule is the result of a Senate report that has caused some consumers to confuse companies with the government’s Medicare program. The proposed regulation would prohibit plans from using the Medicare logo and would require the company behind the advertisement to be identified.
“It’s definitely a bow and arrow for brokers and insurers in response to rising complaints about misleading marketing practices,” said Tricia Neumann, executive director of the Kaiser Family Foundation’s Center for Medicare Policy. and her team regularly review TV ads for the plan.
The proposal also allows beneficiaries to opt out of marketing calls for the plan and limits the number of businesses that can contact beneficiaries after they complete a form seeking information. The book described patients who received dozens of unsolicited aggressive marketing calls.
David Lipshutz, associate director of the Center for Medicare Advocacy, said the federal government’s proposed rule didn’t include everything on his wish list, but the goals are broad and important. .
“This is a really meaningful response,” he said. “And where we sit, we don’t say that often.”
Lipshutz said changes will ultimately be determined by how effectively and aggressively Medicare enforces the standards. Today, much of the deceptive marketing is done by brokers, agents and other third party marketing companies, not by the insurance companies themselves. The proposed rule would hold insurance companies accountable for the actions of the companies they hired.
“These proposals are an important step to protect Medicare seniors from fraudsters and unscrupulous insurers and brokers,” Oregon Democratic Sen. Ron Wyden, who chairs the Senate Finance Committee, said in a statement. .
The rule also addresses health plans’ use of technology that requires companies to approve certain care before insurance coverage. Patients and their doctors have complained to Medicare that private plans are abusing the previous approval process to deny them needed care. estimated that they were denied necessary medical care that should have been covered under the program.
The new proposal requires a plan to disclose the medical basis for denial and relies heavily on the involvement of experts familiar with patient care in decision-making. Set up. Patients now often wait up to 14 days. The new regulations will also require approvals covering the entire duration of treatment so that patients do not have to continuously request the same approvals.
Dr. Meena Seshamani, director of the Medicare Center and deputy administrator of the Center for Medicare and Medicaid Services, said the change was influenced by thousands of public comments sought by the agency and lawmakers.
“We feel that this proposed rule would really and meaningfully improve the timely access that people in Medicare need to the care they need,” she said.
The insurance industry has said it generally supports regulators’ efforts to protect Medicare subscribers from deceptive marketing, and the Better Medicare Alliance, a group that supports Medicare Advantage, said: “There should be no room in the system,” he said, agreeing with officials. According to a statement from the group’s chief executive, Mary Beth Donahue.
Donahue added that her group continues to consider the agency’s proposals for how patients should seek preapproval for treatment. He said he hoped to improve the process by
Hospitals, which have called for changes to address concerns that insurance companies are abusing preauthorization, have lauded the proposal. But they stressed that health officials in the Biden administration would have to commit to implementing stricter oversight.
“Government agencies really need to keep an eye on things,” said Molly Smith, vice president of the public policy group at the American Hospital Association, a trade group.
The proposed rule is not yet final. Health officials are seeking public comment and may make changes.