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To the editor: When you opt for Medicare Advantage (MA) instead of traditional Medicare, you place decisions about your health in the hands of a big insurance company intent on making a profit. Three quarters of the MA business is currently in the hands of six huge insurers: Humana, CVS, Anthem, Kaiser Permanente, Centene, and Cigna [https://www.axios.com/2022/01/19/medicare-advantage-2022-enrollment-unitedhealth-humana].

Because of the “potential incentive for Medicare Advantage Organizations (MAOs) to deny beneficiary access to services and deny payments to providers in an attempt to increase profits,” the Health & Human Services agency inspector general just reviewed the performance of MA insurers [https://oig.hhs.gov/oei/reports/OEI-09-18-00260.pdf]. The results were not good. Of the prior approval requests that MA insurers denied, 13 percent should have been approved. Of the payment denials by MA insurers, 18 percent were improper under both the rules of Medicare and the MA insurer’s own rules. Some improper decisions were reversed by the MA insurer, but this often happened only after “a beneficiary or provider appealed or disputed the denial.”

The three causes of these improper denials:

• Using clinical criteria that Medicare does not impose

• Requesting unnecessary documentation

• Errors in the insurer’s manual review or system

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Since every improper denial is a money saver for the insurance company, you have to wonder how intentional this rate of impropriety is. Since every improper denial is a hardship to a patient and/or medical provider, you have to wonder how the government can allow this kind of behavior, while also allowing MA insurers to tout the MA program as God’s gift to seniors.

The government also knows that MA insurers are also manipulating the system to increase the amount of money they get from Medicare [https://www.kff.org/medicare/issue-brief/higher-and-faster-growing-spending-per-medicare-advantage-enrollee-adds-to-medicares-solvency-and-affordability-challenges/], a fiasco that is surely a testament to how much money these insurers devote to “shaping” regulators’ opinions.

It will get worse. Ideas similar to those behind the Medicare Advantage program underlie Medicare’s new mania for “value based care.” The agency recently announced that all Medicare beneficiaries should be in value-based care programs by 2030 [https://innovation.cms.gov/strategic-direction-whitepaper].

Lee Russ

Bennington, May 7