Lawmakers Urge CMS to Improve Data Collection in Medicare Advantage

Four United States Senators have called on CMS to improve data collection and reporting in the Medicare Advantage program to help regulators understand how plan design impacts care quality, cost, and coverage.

In the bipartisan letter sent to CMS Administrator Chiquita Brooks-LaSure, Senators Bill Cassidy (R-LA), Elizabeth Warren (D-MA), Marsha Blackburn (R-TN), and Catherine Cortez Masto (D-NV) highlighted concerning trends in Medicare Advantage.

For example, they noted that the HHS Office of Inspector General (OIG) found in 2019 that 13 percent of prior authorization denials and 18 percent of payment denials by Medicare Advantage plans met Medicare coverage rules. This indicates that Medicare Advantage plans denied or delayed access to care that would have likely been approved in traditional Medicare.

The letter also referenced the steep overpayments to Medicare Advantage plans—at least $106 billion between 2010 and 2019. Projected overpayments for 2023 range from $27 billion to $75 billion.

Publicly available plan-level data would help increase oversight of Medicare Advantage plans and help avoid care denials and overpayments.

The senators urged CMS to collect and publish data on several areas, including prior authorization requests, denials, and appeals by type of service. CMS reports aggregate prior authorization data at the contract level but does not collect data by service type, beneficiary characteristic and health status, or plan.

This makes it difficult for regulators to determine if prior authorization requests, denials, and appeals are more common for certain services or patients or if Medicare Advantage plans are complying with requirements to cover all Medicare Part A and Part B services, the letter stated.

CMS should also collect and publish data on the justification of prior authorization denials. CMS and regulators cannot always assess whether the request was appropriately denied without knowing the reason for rejection.

CMS does not require Medicare Advantage plans to report how long it takes to complete prior authorization requests. Plans can sometimes extend the timeframes by up to 14 days, but the agency does not collect data on how often this occurs. This data would help indicate which services take longer to receive prior authorization and allow beneficiaries to compare response times across plans, the Senators wrote.

The letter requested that CMS collect complete encounter data that include denied-claim indicators. The agency should also gather data on the utilization of supplemental benefits and related out-of-pocket costs. Supplemental benefits are a key part of Medicare Advantage plans, but there is limited data on how beneficiaries use these benefits.

Additionally, the Senators urged CMS to release certain data the agency already collects, including out-of-pocket costs and provider payment information. This data would allow regulators and beneficiaries to understand the different cost-sharing requirements in Medicare Advantage and how they compare to traditional Medicare.

CMS should also publish disaggregated enrollment data to create more transparency around whether certain groups disenroll from Medicare Advantage at higher rates. The letter called for the agency to publicly release plan comparison data as well, which would help beneficiaries compare and select plans.

The Senators requested that CMS provide a staff-level briefing on its plans to improve data collection and reporting practices in Medicare Advantage by December 27, 2023.