Warren, Cortez Masto, Cassidy, Blackburn Call for Better Medicare Advantage Data Collection and Reporting
“Without better data, policymakers and regulators are unable to adequately oversee the program and legislate potential reforms.”
Washington, D.C. – U.S. Senators Elizabeth Warren (D-Mass), Catherine Cortez Masto (D-Nev.), Bill Cassidy (R-La.), and Marsha Blackburn (R-Tenn.) sent a letter to the Centers for Medicare and Medicaid Services (CMS) Administrator Chiquita Brooks-LaSure, raising concerns about shortfalls in CMS’s data collection and reporting practices for Medicare Advantage (MA) plans. The senators are urging CMS to close data gaps to strengthen oversight of MA plans and improve care for Medicare beneficiaries.
“For the first time, over half of all Medicare beneficiaries are choosing to enroll in MA plans. However, in the last few years, federal watchdogs have released numerous reports examining concerning trends in MA… These findings raise important questions about ensuring the integrity and fiscal sustainability of the Medicare Advantage program. Without publicly available plan-level data on prior authorization requests by type of service, timeliness of determinations and reasons for denials; claims and payment requests denied after a service has been provided; beneficiary out-of-pocket spending; and disenrollment patterns, policymakers and regulators are unable to adequately oversee the program and legislate potential reforms,” wrote the senators.
In 2019, the Health and Human Services Office of the Inspector General (HHS OIG) found that among requests MA plans denied, 13 percent of prior authorization denials and 18 percent of payment denials actually met Medicare coverage rules, meaning the MA plan delayed or denied seniors access to services that would have been approved under Traditional Medicare. Because of these alarming delays and denials, which keep more money in the pockets of private insurance companies while hurting seniors, the Government Accountability Office reported that enrollees in MA plans are more than twice as likely as other enrollees to switch to TM during their last year of life
Researchers have also reported billions in government overpayments to MA plans, largely driven by favorable selection and shortcomings in the program’s current risk adjustment model. Between 2010 and 2019, CMS paid MA plans at least $106 billion in excess payments. For 2023, the Medicare Payment Advisory Commission estimates that MA plans may receive $27 billion in overpayments, while others have placed these estimates even higher. These overpayments not only hasten the depletion of the Hospital Insurance Trust Fund, but also increase costs for seniors and taxpayers in the form of higher Part B premiums.
“While CMS already requires MA plans to submit some of these data – such as seniors’ cost-sharing liabilities and enrollment data by demographic – much of this information is collected for internal purposes only or made available with a significant time delay, which further hurts transparency efforts. In both cases, a lack of public data prevents seniors and people with disabilities from making informed decisions about which plan fits their needs,” continued the senators.
The senators are urging CMS to collect and publish the following data:
- Prior authorization requests, denials, and appeals by type of service. CMS does not collect these data by type of service, by beneficiary characteristic and health status, or by plan. As a result, researchers, regulators, and lawmakers cannot evaluate whether prior authorization requests, denials, and appeals are more common for certain types of services or patients, or whether MA insurers are complying with CMS requirements to cover all Medicare Part A and Part B services.
- Justification of prior authorization denials. Without explanation, CMS and regulators are limited in their ability to assess whether prior authorization requests were appropriately denied
- Timeliness of prior authorization decisions. Collecting this data would help researchers track which services take longer than others to receive prior authorization and allow beneficiaries to compare prior authorization response times across plans when selecting coverage.
- Complete encounter data. Encounter data is often incomplete, which makes it difficult to track plan performance.
- Utilization of supplemental benefits and associated out-of-pocket costs. There is little information publicly available on enrollees’ utilization of these benefits, the specific items or services they receive, or associated out-of-pocket spending. These extra benefits are popular with seniors and utilization data would allow CMS to better assess their quality and value.
In addition to requiring MA plans to submit the data outlined, the senators are also urging CMS to publicly release the following data that it is already collecting:
- Out-of-pocket costs and provider payment information. Publicly available MA encounter data does not include any information on provider payments or out-of-pocket liability for beneficiaries. CMS should validate and publish this information in line with existing regulations, to ensure that researchers, lawmakers, and beneficiaries can better understand cost-sharing structures across MA plan offerings.
- Disaggregated disenrollment data. Publishing these data would allow researchers to evaluate whether certain groups disenroll from MA at higher rates than others, and whether disenrollment rates are associated with out-of-pocket costs or coverage denials.
- Plan comparison information. CMS is required to publish a comparison between quality and performance indicators in MA and TM, including information on health outcomes. CMS should ensure this information is up to date and easily accessible on the CMS website to assist seniors in comparing the benefits of MA and TM.
The senators are also asking CMS to provide them with a staff-level briefing on its plan to improve its data collection and reporting practices for MA plans by December 27, 2023.
Senator Warren is been a leading voice on reining in abuses in Medicare Advantage and protecting patients:
- In November 2023, Senators Warren, Cortez Masto, Cassidy, and Blackburn introduced bipartisan legislation to improve transparency of MA plans and ensure these plans are best serving the health care needs of America’s seniors. The Encounter Data Enhancement Act would require Medicare Advantage plans to report important information about how much they are actually paying for patient services and how much patients are responsible for paying out-of-pocket.
- In November 2023, at a Senate Finance Committee markup of the Better Mental Health Care, Lower-Cost Drugs, and Extenders Act, Senator Warren highlighted the need to do more to prioritize hearing health for seniors and strengthen transparency in Medicare Advantage, and secured commitments from Senate Finance Committee leadership to prioritize these proposals in future packages.
- In October 2023, at a hearing of the Senate Finance Committee, Senator Warren called out giant MA insurers for using deceptive marketing tactics to lure seniors into the wrong plans and drown out competition from smaller insurers that may offer better coverage. Senator Warren called on CMS to act within the fullest extent of its authority to crack down on MA insurers that game the system to overcharge the government and to ensure insurers publish accurate data on patient care and out-of-pocket costs.
- In May 2023, at a hearing of the Senate Finance Committee, Senator Warren highlighted the prevalence of ghost networks in Medicare Advantage plans and called for stronger oversight of the program.
- In March 2023, Senator Warren sounded the alarm on a new analysis by policy experts showing that all Medicare beneficiaries – including those enrolled in Traditional Medicare – are paying higher premiums due to overpayments in MA. She sent a letter to CMS and called on the agency to finalize its proposed rule to ensure payments to MA plans accurately reflect the cost of care.
- In March 2023, U.S. Senators Warren and Jeff Merkley (D-Ore.) sent letters to the top seven MA insurers – Humana, Centene, UnitedHealthcare, CVS/Aetna, Molina, Elevance Health, and Cigna – regarding their questionable claims that CMS’s 2024 proposed Medicare Advantage payment rules would hurt beneficiaries.
- In March 2023, at a hearing of the Senate Finance Committee, Senator Warren defended CMS’s proposed adjustments to the Calendar Year 2024 MA payment rates, pushing back against giant insurance companies and their lobbyists who are peddling misinformation to protect their billions in profits and scare beneficiaries into opposing the rule.
- In April 2022, Senator Warren and Representatives Katie Porter (D-Calif.), Rosa DeLauro (D-Conn.), and Jan Schakowsky (D-Ill.) led their colleagues in sending a letter to CMS Administrator Chiquita Brooks-LaSure highlighting concerns about overpayments to Medicare Advantage plans that line the pockets of big insurance companies.
- In February 2022, chairing a hearing of the Senate Finance Subcommittee on Fiscal Responsibility and Economic Growth, Senator Warren delivered remarks about strengthening Medicare and cracking down on pharmaceutical and insurance companies’ corporate greed to pay for expanded coverage.
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