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Chip speaks to Sunitha Reddy about how Medicare Advantage (MA) Abuse can be more than an inconvenience for patients – it can be harmful.
A podcast hosted by FAH’s Chip Kahn that shines a light on everything hospitals; from the advancements in patient care to how a hospital benefits its community.
Chip Kahn:
Hello. Thanks for listening to Hospitals in Focus. In this episode, we are going to examine the challenges with the Medicare Advantage Program. But in the days since we spoke with our guest, Sunitha Reddy of Prime Healthcare, there have been some major developments. CMS has released two separate proposed regulations that address aspects of prior authorization in Medicare Advantage, as well as Medicaid and ACA private plans. The two rules address some of the challenges highlighted in this podcast, and the proposals may help ameliorate certain of the abuses directly affecting patients that you will hear outlined by Sunitha. The proposed regulations are open for public comment. Thanks for listening, and now on to our episode.
Speaker 1 (00:05):
Welcome to Hospitals in Focus from the Federation of American Hospitals. Here's your host, Chip Kahn.
Chip Kahn (00:15):
Medicare Advantage, otherwise known as MA, includes almost half of all Medicare beneficiaries. In fact, this year, more than 28 million seniors are enrolled in MA plans. And MA is on a growth path to become the dominant part of Medicare in many states across the country. This means that many of our most vulnerable seniors will on the one hand receive the added benefits and discounts that these plans offer upfront, but may find pathways to care more difficult than they bargained for when they signed up for coverage. This would appear to be a story about providers, but in fact, it is about practices that at best, inconvenience and at worst are harmful for patients.
(01:05):
Joining us to talk about MA abuses is Sunitha Reddy, the Chief Revenue Officer, Vice President of Operations for Prime Healthcare. For those of you who do not know, Prime is the fifth largest tax paying health system in the country with more than 45 hospitals in 14 states, 300 outpatient locations, as well as nearly 50,000 employees and affiliated physicians. From her position, Sunitha has a unique perspective on the role MA plays in healthcare and the impact it can have on those seniors plan members who need hospital care. Sunitha, welcome, we're so happy to have you today.
Sunitha Reddy (01:50):
Thank you for having me on the podcast, Chip. It's great to be able to speak with you today, especially on such an important issue. And on behalf of all of us at Prime Healthcare, thank you and the federation for your continued advocacy and support on behalf of hospitals and the communities they serve.
Chip Kahn (02:07):
Great. Sunitha, let's get started, we know just how integral MA is to the care and coverage of so many, but let's take a step back and discuss the origins of Managed Care in MA. And from your perspective, what was the original goal of MA, and how has that evolved?
Sunitha Reddy (02:27):
Medicare Advantage was originally intended to leverage the innovation of the private sector to expand, enroll choice and access to care, as well as to decrease cost. Medicare Advantage, also known as Part C, was created as part of the Balance Budget Act in 1997 and essentially authorized Medicare to contract with private health plans to accept full responsibility for the costs or take risk for these beneficiaries in exchange for a predetermined risk adjusted monthly per enrollee payment. The role of Medicare Advantage has steadily been growing and, as you mentioned, is more than doubled and currently accounts for about 55% of total federal Medicare spending.
(03:09):
While the initial goals of Medicare Advantage to increase consumer choice and lower costs were well-intentioned, they're definitely unintended consequences due to the current practices of private health plans and the lack of government oversight that's led to decreased access for needed patient care and negative patient outcomes. And in the absence of strong oversight, Medicare Advantage plans have developed a number of different problematic operating policies and protocols which systematically deny coverage to beneficiaries to maximize profit and have been extremely effective.
(03:42):
Medicare Advantage plans, as you know, have become among the largest and most profitable plans in the nation, and as of 2021, the five largest insurers, United, Humana, Aetna, Kaiser, and Anthem account for 67% of enrollment in Medicare Advantage. The scale of these large plans gives them enormous market power and allows them to really squeeze providers on rates and dictate operational terms. And so providers have been pushed to accept lower rates and deal with burdens and processes to keep patients in network and maintain access for seniors. So unfortunately, the privatization of one of the nation's greatest public welfare programs, Medicare, has led to unintended consequences and abuses by organizations that limit coverage and access to care to those that need it most.
Chip Kahn (04:30):
Earlier this year in April, the HHS office of the Inspector General released a new report indicating that MA plans often shortchange their patients by denying as many as millions of requests for care, which is medically necessary. This report notes and I quote 'CMS annual audits of MA plans have highlighted widespread and persistent problems related to inappropriate denials of services and payments.'
(05:01):
Have Prime patients experienced these types of problems, and where have the MA plans gone with denying coverage that would've been provided under traditional Medicare? In these cases, from your experience, what happens to the patients?
Sunitha Reddy (05:16):
Absolutely, Chip. Prime hospitals across the country have experienced these exact same issues. With regards to prior authorization denials, MA plans are supposed to follow Medicare coverage rules, which specify what items and services are covered and under what circumstances. And MA plans are required to provide beneficiaries with all basic benefits covered under traditional Medicare and aren't supposed to impose additional restrictions like waiting periods or exclusions from coverage due to preexisting conditions.
(05:45):
However, we have hundreds of examples each year where Medicare Advantage patients are scheduled for necessary outpatient procedures or for testing, but the MA plan fails to provide timely authorization and providers are forced to reschedule the procedures until a valid authorization from an MA plan is issued, which could sometimes be days or even weeks. And so these prior authorization requests lead to delays and needed care for seniors and place undue burden on hospitals and patients. If these authorizations aren't obtained prior to service, providers don't get reimbursed and providers and patients have to enter into really cumbersome and time-consuming appeal processes with the health plan to request authorization and reimbursement for the care that was provided.
(06:30):
And Chip, while not discussed in the OIG report that you mentioned, we also see the same authorization denial practices from MA plans for emergent inpatient care. MA plans routinely fail to provide timely authorization determinations and often don't even provide a response until well after the patient's been discharged from the hospital. As you know, the hospital must provide care often for lifesaving emergency services regardless of whether the plan responds to a request for authorization. Sometimes, an MA plan will deny the claim for lack of ATH and then request additional medical records post discharge then retrospectively deny the level of care provided and not reimbursed hospitals until they go through a long and lengthy appeals process.
(07:18):
Patients are actually directly impacted by this as well. When a plan denies authorization, this impacts the patient's cost share, so patients are left not knowing what their cost share is or copay or what their copay will be or even whether their care is approved. We don't have this problem with traditional Medicare because they don't have these prior authorization requirements for inpatient level of care. And the imposition of these requirements from MA plans undermines the financial solvency of the healthcare system and, as mentioned, adds undue burden on both patients and providers.
(07:51):
Another area that is mentioned in the OIG report is regarding claims payments. MAOs in the OIG report denied 18% of claims that Medicare coverage and billing rules, which delayed or prevented payments for services providers that already delivered. And our hospitals have experienced the exact same issue as it relates to MA claims and processing type errors, including MA plans overlooking medical documentation in their review, not updating claim systems timely to reflect contracted and in-network claim status, and misapplying Medicare coverage rules in order to deny care.
(08:30):
But Medicare Advantage claim denials and underpayment issues go far beyond prior authorization and claims processing errors. Private MA plans are financially incentivized to deny Care and have been implementing a number of different tactics to deny or underpay claims, including the use of third party companies to perform claim audits or to recoup payments as well as the use of intentionally complex and peer specific criteria in order to deny claims. Many MA plans have been subcontracting with third party auditors to conduct reviews of claims and intentionally pull back payments that have been made to providers.
(09:07):
One common example is DRG downgrades. MA plans have been leveraging these auditors to downgrade the DRG to a lower reimbursing DRG, either by changing the DRG entirely or by removing a comorbid condition or major comorbid condition, also known as CCs or MCCs from the patient record. And this is troublesome for a number of different reasons, including reviewers are not following Medicare and HMEA coding guidelines. And just for reference, based on our appeals' data from the prime perspective, less than 3% of appeals for DRG downgrades are actually getting overturned despite having appropriate documentation and coding documentation and review. For reference, last year we had over 5,000 DRG denials just from MA plans alone.
(10:00):
Another example is recruitments of outlier payments from MA plans. Medicare compensates hospitals extra reimbursement for patients stays that substantially exceed the typical reimbursements for extreme inpatient cases. Some MA plans are also leveraging companies to audit claims and actually remove line item charges in order to not make those claims reach outlier threshold and then to recoup the outlier payment amount. DRD downgrades, and line item reviews are just a few of the practices that MA plans are leveraging that are not utilized by traditional Medicare and highlight some of the intentional abuses by MA plans to underpay claims. In addition to these tactics, private MA plans are harming patients and providers by not following Medicare criteria to authorize or to reimburse claims and rather applying their own complex payer specific criteria to authorize or deny claims.
Chip Kahn (10:57):
That last point you made is really troubling, let's dig deeper into that. If they're not using Medicare criteria, what type of criteria are the plans using to make these medical decisions?
Sunitha Reddy (11:12):
Great question, Chip. MAOs are supposed to follow traditional Medicare coverage rules when determining whether to authorize or pay for a service, but that's not what is happening. Most MA plans don't follow Medicare coverage rules, and while some plans agree to follow certain industry standard clinical care guidelines like Milliman or InterQual in their contracts, they often use these guidelines inconsistently and usually incorporate their own proprietary clinical protocols to deny authorization or inpatient care. MA plans quite literally make up their own clinical criteria in what are typically confidential policies that are designed in their committees without the meaningful transparency and input from hospitals and providers.
(11:57):
Plans have final say on these often secret clinical criteria, which grant wide discretion to their own utilization management teams and medical directors who are essentially incentivized to deny coverage. So emmic plans claim to provide transparency by posting broad information on medical necessity criteria on their provider manuals, which they usually will post to their websites, but typically the information posted is generic, vague, and ever-changing to allow for health plans to use the criteria as they see fit.
(12:30):
Another thing is, Medicare advantage plans are not following Medicare coverage criteria for outpatient pre-authorizations by including their own criteria, which is above and beyond Medicare, which simply uses NCD or LCD coverage guidelines and are requiring authorizations which Medicare does not do, which further delays patient care. On the inpatient side, traditional Medicare does not have specified clinical criteria and typically defers to the decisions made by the treating physician or CMSs to midnight rule.
(13:03):
In general, the rule helped to clarify that Medicare would pay for inpatient services if the admitting practitioner expected the patient to require a hospital stay that crossed to midnights and the medical records supported that reasonable expectation. But MA plans do not follow this Medicare guideline and rather use their own criteria to determine medical necessity regardless of the patient's length of stay. The health plans will often deny inpatient level of care and downgrade to observation to delay payment or decreased reimbursement to providers while they've been providing critically needed care to elderly patients.
(13:40):
I can maybe speak to an example from one of our prime hospitals where a senior patient with the history of congestive heart failure was admitted for acute exacerbation of chronic systolic and diastolic heart failure along with acute worsening renal failure and had a number of other issues. The patient was admitted to the ICU, had an implantable cardiac defibrillator placed, and underwent hemodialysis. And after nine days of life extending efforts, unfortunately and sadly, the patient passed away. The Medicare advantage plan did not provide authorization and stated the patient didn't meet an inpatient hospital level of care and denied the case as not medically necessary. Even after exhausting all of our appeal efforts, the plan never overturned the denial or paid for services.
Chip Kahn (14:26):
As I said in the previous question, this, in a sense, is troubling with an exclamation point. And you give this example, which clearly shows that practices that the MA plans are undertaking threatens patients and threatens care. Can you give me some other examples of specific instances that you may have from your experience where the care was either prevented or was not paid for because of how the MA plans are evaluating the cases that their members undergo?
Sunitha Reddy (15:02):
Absolutely, Chip. The majority of our patient population at Prime's Hospitals are seniors and we care deeply about meeting their unique needs and providing the highest quality of care. Unfortunately, Medicare Advantage plans have really put profits over patient care leading to devastating results. We see countless examples of patient care being impacted on a daily basis. For example, issues related to the lack of network adequacy. Many MA plans don't have enough contracted or in-network post-acute care organizations to support their patient's needs. On the provider side, we often have Medicare advantage patients ready for discharge from the inpatient setting, but there are not medically appropriate post-acute care facilities available. In some cases, MA plans continue to deny hospital authorizations despite their own network adequacy issues leading to delays in finding post-acute care placement for patients and delays in transferring these patients due to the unavailability of beds at in-network facilities.
(16:04):
One case that we had, was a senior patient with the history of drug abuse, depression, traumatic brain injury that was brought in by EMS for evaluation for altered mental status and for flu-like symptoms. Well, the patient ended up being COVID positive and was placed on supplemental oxygen and treated but was not safe to be discharged home and required skilled nursing care. Once ready for discharge, the hospital case management called five different contracted sniffs before the patient was able to be transferred. Four SNIFFs rejected the patient due to capacity and COVID status. And what's so frustrating, is later the payer denied the authorization for inpatient stay as not medically necessary despite significant effort that the hospital made to transfer the patient to a contracted SNIFF. That claim was denied and still hasn't gotten overturned despite numerous appeals. I think this example highlights the delays in patient care for post-acute services with MA plans, both from a network adequacy standpoint but also from an authorization standpoint.
(17:07):
Critically needed care is getting delayed or flat out denied, and these delays in post-acute transfers are leading to longer than needed hospital stays, which prevent patients from getting cared for in the appropriate setting and ultimately leads to problems with access. I can provide another example that highlights how health plan dynamics have gotten in the way of caring for seniors which relate to psychiatric and behavioral healthcare. According to a recent study published by JAMA, the percentage of the US population reporting serious psychological distress has risen from 4% in 2018 to 13% in 2022. While psychiatric facilities have experienced disrupted continuity of operations and reduced bed capacity, obviously only exacerbated by the COVID-19 pandemic, Prime has tried to address the shortage in psychiatric beds in the US and has actually opened neuropsych programs across the country to focus on essential behavioral healthcare needs for seniors.
(18:06):
As I mentioned, traditional Medicare does not require authorization for these inpatient site cases as there's clear need for this type of care for the elderly. However, MA plans do require continued state authorizations and routinely deny care as not medically necessary. For example, earlier this year, an MA patient was diagnosed with schizoaffective disorder, severe depression, and psychotic features, and was hospitalized in one of our hospitals for about a month. The hospital received it now from the MA plan due to lack of medical necessity, and the MA plan only approved half of the days. The attending psychiatrist who was actually treating the patient called for a peer-to-peer to discuss the clinical necessity of the case, but the medical director at the health plan upheld the denial and stated that the care was not medically necessary. And then the hospital had difficulty placing the patient into SNIFF, again, highlighting issues with network adequacy.
(19:00):
I think these examples show how access to needed care is limited and how much additional time and resources are wasted in the authorization process for inpatient psych services and for post-acute care. Also, we can't really expect a patient suffering from severe mental health issues to go through and enter into a cumbersome and lengthy appeals process with the MA plan to get this overturned.
Chip Kahn (19:24):
Sunitha, you have outlined a number of areas of abuses related to prior authorization, down coding, care denials, and questions about network adequacy. What can be done to address these problems? And then separately, how can the appeals process be changed to come to grips with these problems in terms of the patient needs, which seem to be ignored in this process?
Sunitha Reddy (19:55):
Sure. Let's start with some of the issues with the appeals process. First, Medicare Advantage plans have intentionally designed the appeals process to be extremely difficult to comply with, or at least that's our experience. I mentioned that the five largest health plans have close to 70% of all Medicare advantage beneficiaries, which puts extreme pressure on hospitals to accept whatever network contract these plans are offering. And these contracts often include extremely burdensome processes to appeal, often requiring numerous written appeals and the use of specific provider templates and forms in order to be accepted. All of our appeals need to be done perfectly with insured amounts of time and any minor mistake is grounds for default for the appeal to get thrown out.
(20:41):
Second, these appeal processes are extremely time and resource intensive. Many hospitals use their nurses and case managers to appeal when authorizations are denied or when a claim is denied for medical necessity of often having to appeal on the patient's behalf. Providers are essentially appealing to the plan that initially denied the care and are financially incentivized to continue to deny the care and underpay the claim. The plans say they offer multiple levels of review, but often, at least based on our experience, the appeal just moves to a different reviewer at the health plan that simply rubber stamped the initial denial. A very small percentage of denials are actually overturned, at least from our experience, further demonstrating that the MA appeals process is illustory and the lack of accountability from MA plans to appropriately review these cases.
(21:30):
I think there are some common sense solutions that would have a profound impact on curtailing the current abuses and restoring protections for beneficiaries. Transparency is a starting point. MA plans should be required to report on all denial and appeals data to CMS and with this data, also include information on current consumer complaints. And all of this information should be included on the plan's explanation of coverage document that's shared with potential enrollees. This would help inform the public, so consumers can meaningfully compare plan options and know for themselves which plans have a history of bad practices that put profits over patients. And it would enable consumers to best weigh the benefits and disadvantages associated with choosing health coverage.
(22:15):
I think standardization would be the next step. CMS and Congress should implement a set of minimum standard patient protections that plans should abide by. For example, MA plans should follow all CMS payment policies and standards such as the two midnight rule, which we discussed. Medicare Advantage plan should also be required to provide timely concurrent authorizations and be prohibited from later denying coverage for services they express they authorized at the time of treatment. At a really basic level, medicare Advantage plans should follow Medicare guidelines with respect to authorization and with respect to claim payment processes.
(22:53):
Lastly, I think CMS should have proper oversight of MA plans, especially with regards to authorizations, payment, and appeals processes. And there should be a way for providers to escalate these unfair payment practices and issues directly with CMS. For example, when providers are non-contracted with a Medicare advantage plan and an MA plan makes an adverse reconsideration decision, the provider can mandate that the plan submit the case file and its decision for review by an independent review entity or IRE.
(23:24):
When you are contracted with the MA plan however, the plan is not required to go through the CMS defined process and you're essentially stuck with the appeals processes that are outlined in the contract. CMS should have oversight of MA plans regardless of contract status, and all providers should have the option to escalate these issues through an independent review process under CMS.
Chip Kahn (23:45):
Sunitha, all these discussions about MA are relevant to pre COVID and obviously post COVD, hopefully we're working our way out of the epidemic pandemic. But it's hard to have a discussion about any aspect of healthcare without looking back at the last 30, 36 months. During that period of COVID, particularly with many of your hospitals experiencing more than one surge in COVID-19 cases, did the MA issues that we've been talking about get better or worse?
Sunitha Reddy (24:23):
Unfortunately, Medicare advantage issues did not improve and were even worse unfortunately during the height of the pandemic. Despite CMS encouraging MA plans to relax prior authorization requirements, many MA plans continued to keep their same utilization management and authorization processes in place even during the COVID surges. As you can imagine, this was extremely difficult on hospital staff who were already understaffed and pulled time and attention away from frontline clinical caregivers who were still required to comply with prior authorization and appeal requirements while still managing really critical patient caseloads.
(25:00):
Further compounding the issue during the pandemic, many health plans were actually facing their own staffing shortages and challenges, which led to even more delays in timely authorization. So in addition to the non-compliance with CMS waivers regarding relaxing auth requirements, we continue to see denials for lack of authorization and medical necessity even for MA beneficiaries who are even being treated with COVID. We have so many examples of MA patients that were COVID positive and treated with Remdesivir, which sometimes requires five full days of course treatment that were denied for lack of authorization or retrospectively denied for lack of medical necessity.
(25:41):
One case example was, a senior patient that was diagnosed with COVID-19, pneumonia, sepsis, acute respiratory failure and acute renal failure, and was admitted to the ICU. The patient was in one of our hospitals for 26 days and the plan initially provided authorization, however, the MA plan subsequently asked for medical records well after the patient was discharged and then pending their review, they denied the stay. And we've exhausted all of our appeal efforts for this claim and it remains underpaid over a year and a half later. And we have numerous examples where MA plans retrospectively denied COVID cases as not medically necessary and either never paid the claim or recouped payments, but network adequacy issues were also exacerbated during the pandemic.
(26:29):
Many post-acute care facilities were ill-equipped to deal with COVID-19 patients, and MA plans failed to facilitate timely placement for these patients and patients faced delays due to pending authorizations for SNIFFs and other post-acute care settings and providers faith denials for discharges. We have an example where patients were ready to be discharged to a SNIFF, but the MA plan took over a week to find an available facility for the patient and issue authorization. And when the patient was finally transferred to the SNIFF, the MA plan came back and denied the hospital stay, stating the last few days of the inpatient stay were not medically necessary and then denied the entire stay and never reimbursed the hospital for the inpatient care provided to the patient.
(27:13):
I think the pandemic really highlighted the striking differences between traditional Medicare and managed Medicare and the negative impact on patients and providers. One of the main principles of privatization was supposed to be that, private plans could respond more quickly and better adapt to patient needs. But during the surges, it was actually CMS and traditional Medicare that was really quick to respond and help patients and providers. For example, through the Medicare accelerated program and the new COVID-19 treatment add-on payments, which were meant to help cover the cost of providers who used more costly life-saving drugs like Remdesivir to treat COVID patients.
(27:52):
Many MA plans chose not to follow traditional Medicare guidelines, and they did this by not following, like we talked about, the waivers, ventro relaxed preop requirements, not eliminating burdensome administrative processes during the crisis and even choosing not to pay for add-on payments that Medicare was providing for treating their COVID positive Medicare beneficiaries. Essentially, MA plans only choose to follow Medicare guidelines when it's advantageous to them, it seems.
Chip Kahn (28:21):
Sunitha, you've covered the waterfront so well and particularly you covered the actions that CMS itself should take to try to remediate some of the issues that you've raised that frankly get in the way of patient care. There is action though that is encouraging in the Congress, the house passed a bipartisan bill improving seniors timely access to Care Act, it's now being considered in the Senate and possibly could be taken up at the end of this year or beginning of next year.
(28:56):
Could you talk a moment, as we close out, about that bill which deals directly with these unnecessary delays and denials from prior authorization, and how useful do you think that bill would be if it passes?
Sunitha Reddy (29:11):
Sure, absolutely. I think CMS and Congress both have critical roles in protecting America's seniors, and I truly hope that Congress gives serious consideration to the improving seniors timely access to care Act. Patients desperately need prior authorization reform, and this would immediately eliminate barriers to care. From my perspective, MA plans should follow Medicare criteria like NCD or LCD guidelines on the outpatient side and Medicare's two-minute rule on the inpatient side. I think this would improve timely access to care, eliminate resource intensive processes, and prevent plans from denying necessary care by using their own subjective criteria.
(29:52):
But if MAOs are found to be non-compliant, CMS should enforce monetary penalties. If beneficiaries are not able to access needed services and providers should be paid interest on unpaid claims that are deemed inappropriately denied. CMS should also dramatically increase the network adequacy requirements on plans. These plans are juggernauts making record profits and they can absolutely expand their networks at all levels from primary care to acute care, specialty services, and especially post-acute care, which is so important for seniors.
(30:25):
I think the current standards are simply far too low, which results in patient suffering through lengthy delays for appointments or having to travel long distances for care. This is avoidable and can be changed promptly if CMS increased the network adequacy requirements. I think the only way MA plans will modify or alter their current practices is if CMS mandates these requirements and implements frequent checks to ensure that the plans are compliant. These are just some of the ways to add more regulatory reforms on MA plans, I know there's so much more CMS and Congress can and should be doing to protect Medicare Advantage beneficiaries.
Chip Kahn (31:01):
Well, Sunitha, thank you so much. Your experience, your expertise, and your insight has been so helpful today to get a handle on what are these issues around MA abuse that obviously affects those trying to provide care, but more importantly, affects the care needs of Medicare beneficiaries. So with that, we'll close out and just I appreciate your being here today.
Sunitha Reddy (31:28):
Thank you, Chip, this has been a great discussion. It's really an honor to have this opportunity to share our insights and highlight the importance of needed reform. So on behalf of Prime, thank you again for all of FAH's continued efforts and your leadership.
Speaker 1 (31:47):
Thanks for listening to Hospitals and Focus from the Federation of American Hospitals. Learn more @fah.org. Follow the Federation on Social media at FAH Hospitals, and follow Chip at Chip Kahn. Please rate, review, and subscribe to Hospitals in Focus. Join us next time for more in-depth conversations with healthcare leaders.