Leaders of Three Key Health Committees in Congress Call Out Medicare Advantage Insurers for “Failing to Deliver”

As the Medicare open enrollment period continues, Democratic leaders of the Senate Finance Committee, House Energy and Commerce Committee, and the House Ways and Means Committee sent a letter today to the Centers for Medicare and Medicaid Services illustrating how privatized Medicare Advantage (MA) plans are “failing to deliver” for seniors and people with disabilities. The letter specifically mentions the delays and denials of care using prior authorization, the “bait and switch” in marketing MA plans, and the misaligned incentives for brokers to promote only some MA plans. This letter is a significant development in the continued scrutiny of Big Insurance companies that run MA plans because it signals a shared focus on MA and alignment on necessary reforms from the top three Democratic members of Congress with jurisdiction over this issue. 

Chair Ron Wyden and Ranking Members Frank Pallone and Richard Neal suggest reforms to the prior authorization process in MA that have potential to decrease delays and denials of care. They suggest making data on the use of artificial intelligence (AI) and algorithms in coverage decisions public, including the denial and appeal rates and types of care that are being denied. This would certainly help in understanding the extent of the malignancy that is care denials. Current research on this issue is limited by data availability so it is likely we do not even know the full extent to which Big Insurance is refusing care to seniors and people with disabilities on MA. 

The members of Congress also recommend that MA plans disclose the methodology behind the AI tools and algorithms they use to review prior authorizations. This is a key recommendation because physicians and other medical professionals have reported that when they try to gather information on why the insurer’s algorithm denied their patient’s care they are told “that's proprietary.” When Big Insurance withholds the methodology behind their AI tools making coverage decisions ensures that doctors and patients have no recourse to fight care denials and makes it harder for patients to get care.

These actions by insurance corporations also likely violate the law which states that MA plans must use utilization management guidelines that “are developed in consultation with contracting physicians” and that the guidelines “are communicated to providers.” The recommendation by Ron Wyden and Frank Pallone and Richard Neal for transparency in AI used in MA is vital, and likely supported by existing law and regulation. 

The letter also recommends ensuring that MA network directories accurately list providers within the network to enable people to determine if the plan has the medical providers they require for their care. As health insurance companies become more complex and opaque, it is increasingly difficult to find a provider in network for medical care.

Further, Big Insurance puts the burden of determining if a doctor is really in network by adding disclaimers to their website and phone recordings claiming “This information is subject to change at any time. Please check with the provider before scheduling your appointment or receiving services to confirm he or she is participating in your health plan’s network.”

If a patient receives services from a doctor listed on their insurance plan’s network, but the information is out of date, the insurer can deny the claim stating that the provider is out-of-network and cite the disclaimer as a way to avoid paying for services. For all the talk from Big Insurance that they can administer health coverage more efficiently than other entities, it makes sense to make them do the work to ensure their directories are accurate and honor visits to any medical provider that was listed in network at the time the appointment was made, even if that information was incorrect on the insurer’s network directory. 

Finally, the letter’s authors recommend detailed reporting of how insurance companies and subcontractors are spending money on marketing and broker’s commissions. They also suggest increasing funding for public State Health Insurance Assistance Programs (SHIPs) which provide unbiased assistance to enrollees in choosing their Medicare plan. These reforms would be a big step towards avoiding the misaligned incentives for brokers to steer people into certain MA plans that provide the best commissions, without regard for the quality of care that MA plan provides.

A further step that would provide even more education and support for beneficiaries in choosing their Medicare plan would be to prohibit the use of taxpayer dollars on marketing and brokers by MA insurers. Instead, the $6 billion that Big Insurance currently pays for these services and those incessant commercials about their MA plans could be re-routed to SHIPs to increase their capacity to provide resources and advice on how to choose the best Medicare benefits. 

The letter from Chair Wyden and Ranking Members Pallone and Neal places focus on important issues in MA and charts a path for potential reform in the next Congress. The recommendations in the letter demonstrate that the leaders of key Congressional committees understand the dangers of MA and what needs to be done to curb them. In addition to the recommendations in the letter, action to stop the $140 billion per year in overpayments going to Big Insurance running MA plans would complement this set of reforms perfectly and protect Medicare for decades to come.