AHIP Calls For More Accurate Federal Reporting on Medicare Advantage

AHIP acknowledged the need for improved oversight for certain Medicare Advantage quality metrics but also argued that federal reporting on Medicare Advantage plans has been inaccurate in the organization’s statement for a hearing for the House Committee on Energy and Commerce on Medicare Advantage oversight.

The payer organization argued that OIG reports have diminished the progress that Medicare Advantage plans made in claims denials through prior authorizations and the quality that plans have achieved.

“It is essential that the MA program is evaluated fairly and that appropriate funding mechanisms continue to be available to ensure that millions of seniors and people with disabilities who rely on MA plans continue to receive the high-quality, coordinated care they deserve,” the statement explained.

The OIG report focused on a small number of claims denials that occurred due to Medicare Advantage plans’ prior authorization systems. AHIP pointed out that nearly all requests are approved (95 percent in 2018), according to the OIG data. 

Moreover, the report also highlighted an improvement in prior authorization approvals, with issues per audit dropping around 70 percent over a seven-year timeframe.

“While the OIG raised questions about a small number of the remaining denials, a key concern they identified was the need for additional CMS guidance on the criteria plans are permitted to use in determining coverage. AHIP supports such clarification,” the AHIP statement said.

Prior authorizations have demonstrated the ability to impact quality of care, affordability, and patient safety, AHIP stated citing one of their surveys.

However, while prior authorizations have played a key role in controlling healthcare spending, the tool is by no means perfect. 

AHIP pointed to its Consensus Statement from 2018 in which the organization, along with other stakeholders, called for improvements to prior authorization. Specifically, the statement advised adopting electronic prior authorizations. AHIP followed this statement by initiating the Fast Prior Authorization Technology Highway to explore electronic prior authorizations.

Based on this initiative’s findings, AHIP has recommended that the industry increase electronic prior authorization adoption among providers by expanding access to the necessary technology and supporting and incentivizing providers as they integrate existing electronic prior authorization technologies into their workflows.

In addition to responding to the OIG report’s concerns about Medicare Advantage prior authorizations, AHIP also found issues with OIG’s reporting on risk adjustment in Medicare Advantage. OIG had expressed concerns about the number of diagnoses through health risk assessments in Medicare Advantage. 

However, AHIP said that the report found nothing wrong with these assessments.

Moreover, although a MedPAC report found that Medicare Advantage program risk scores are higher than original Medicare and suggested that this leads to higher payments for Medicare Advantage plans, AHIP argued that original Medicare risk coding is inaccurate and not a viable benchmark.

A report from the Government Accountability Office raised questions about the disenrollment rate from Medicare Advantage in the final year of a beneficiary’s life. AHIP said that the GAO report did not identify access to care barriers.

“While oversight of disenrollment rates may be one metric for CMS to evaluate when overseeing MA plans, the data need to be assessed in context and combined with additional analyses before drawing inappropriate conclusions about care access,” the AHIP statement noted.

In addition to defending prior authorizations and spotlighting certain facets of OIG reporting, AHIP also offered evidence for Medicare Advantage plans’ efficacy overall.

The health plans have been proven to excel on quality measures and on overall efficiency, surpassing original Medicare’s quality level. They also have to ascribe to certain network adequacy standards.

Medicare Advantage plans produce savings for the Medicare program and offer higher value for members and taxpayers. In particular, Medicare Advantage plans offer strong value to members who are lower-income and underserved.

Lastly, AHIP pointed out that these plans have bipartisan support.

Better Medicare Alliance also submitted comments to the Subcommittee on Oversight and Investigations of the Committee on Energy and Commerce.

The subcommittee held the meeting on June 28, 2022.