Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid

Policy & Regulation News

Are Medicare Health Plans Improving or Getting Weaker?

By Elizabeth Snell

- With Medicare’s open enrollment period starting tomorrow and running through December 7, the debate is on over the success of Medicare health plans. Critics are upset that the same deficiencies keep happening, while the Centers for Medicare and Medicaid Services (CMS) state that Medicare plans continue to improve.

According to the New York Times, federal officials have penalized Medicare health plans for numerous deficiencies. For example, even insurers that are highly ranked by the National Committee for Quality Assurance, a private nonprofit group, have been cited for “serious violations” of Medicare’s patient-protection requirements.

“It’s unforgivable that so many Medicare Advantage plans are still struggling with basic compliance issues,” John K. Gorman, a former Medicare official who is a consultant to many insurers, told the Times.

Citing data from CMS, the news source reported that in more than half of all audits, “beneficiaries and providers did not receive an adequate or accurate rationale for the denial” of coverage when insurers refused to provide or pay for care.

Moreover, insurers typically failed to consider clinical information provided by doctors and failed to inform patients of their appeal rights when they were making decisions.

In terms of prescription drug coverage, the Times explained that insurers “inappropriately rejected claims” in the majority of audits – 61 percent of cases. Additionally, insurers enforced “unapproved quantity limits” and required patients to get permission before filling prescriptions when such “prior authorization” was not allowed.

However, it is not all bad news that is swirling about Medicare health plans.

CMS Administrator Marilynn Tavenner released a statement last week discussing the Medicare program. According to Tavenner, quality is improving for both the Medicare Advantage and the Part D Prescription Drug Program. Specifically, 60 percent of people who have a Medicare Advantage Plan are currently enrolled in plans with four or more stars for 2015, compared to an estimated 17 percent back in 2009. Moreover, Medicare Advantage enrollment is projected to reach an all-time high in 2015, with more than 16 million beneficiaries, Tavenner said.

For 2015, the number of Medicare Advantage Plans and prescription drug plans earning four or more stars increased by 6 and 36 percent, respectively, compared with 2014, Tavenner explained.

“Improved quality in Medicare health and prescription drug plans is just one of the many positive changes we’ve seen since the Affordable Care Act was signed into law,” Tavenner said.

Additionally, Medicare premium costs are meeting or beating expectations for the fourth straight year. According to HHS, premiums will be “at least $125 lower over the course of a year then what the Congressional Budget Office (CBO) estimated for 2015 back in 2009.”

CMS also announced last week that most seniors who have Original Medicare, the 2015 Part B premiums will remain unchanged for a second consecutive year. Americans enrolled in Medicare Part B will see premiums and deductibles remain unchanged in 2015 at $104.90 and $147, respectively. It was explained that the premiums could stay the same because of slower Medicare healthcare cost growth since the passage of the Affordable Care Act.



Join 30,000 of your peers and get free access to all webcasts and exclusive content

Sign up for our free newsletter:

Our privacy policy

no, thanks

Continue to site...