Balancing Medicare Advantage Denials for Patients With Diabetic Macular Edema

Every year, millions of medical service insurance claims are denied by health care providers. Some of these denials are necessary, as they are to avoid wasteful medical. However, many denials can further delay a diagnosis and treatment for a patient with diabetic macular edema for example. Patients with Medicare Advantage (MA) feel the pressure of a late diagnosis and  treatments for their conditions. MA plans are allowed to leverage utilization management tools, which include prior authorization. Of the 35 million prior authorization requests submitted in 2021, 6% were denied, and 11% of these denials were appealed with 82% of the appealed cases overturned. For many patients with MA coverage, this high overturn rate makes patients question if providers are not meeting their obligations for coverage.

In 2022, researchers found using data from large insurance claims that approximately one third of MA insured patients experienced a coverage denial for one or more services every year. The denials increased at a rate of 15% over 5 years. 15% of the MA policies that were responsible for the 5.6 million denials were also found to be more restrictive than traditional Medicare policies. The researchers believed the data suggested that MA plans may deny coverage that Medicare would normally approve, the Office of the Inspector General (OIG) confirmed this claim. One denial provided by the OIG was from a 76-year-old with postpoliomyelitis syndrome, who was denied a mobility walker because he received a cane 5 years beforehand. Because of this, the US Centers for Medicare and Medicaid Services (CMS) created a final rule stating that both MA and Medicare enrollees should have the same restrictions, and MA coverage cannot be more restrictive than traditional Medicare. This rule will affect many Medicare and MA beneficiaries, including those diagnosed with diabetic macular edema.

However, Medicare and MA policymakers understand that they will need to navigate between reducing denials of necessary services and over-approving wasteful services. Alignment of coverage criteria does increase the risk of patient service waste. For example, Medicare wastes billions of dollars on a drug for diabetic macular edema, called aflibercept, when bevacizumab is just as effective and a cheaper alternative. Thus, MA plans might require substitutions of medications that have the same efficacies but are significantly cheaper. The US Congress’s new rule for Medicare and MA may make it harder for health care providers to reduce the cost of care. Medicare’s coverage policies are also unclear to both providers and patients. Coverage decisions rendered at the local level by Medicare administrative contractors can give inconsistent results and vary across states. With this new rule, Congress needs to ensure that policies are developed with a standardized evidence-based process throughout all states.

Looking towards the future, CMS needs to require transparency on MA claim denials by providing how and why services are denied for beneficiaries. Denial rates should be available to the public, and CMS should require brokers to tell new clients about the denial rates with MA plans and why/how services are denied. One way CMS could ensure MA accuracy is to leverage audits and fines with price transparency requirements. A list of services denied by MA plans but covered by Medicare also needs to be created to establish what coverage needs to be adjusted to enforce coverage parity. Another strategy the CMS could take would be to use quality star ratings for MA plans that include the metrics for denials, to discourage unnecessary denials.

Reference

Suhas G, Kadakia KT, Tsai TC. Coverage denials in Medicare Advantage—Balancing access and efficiency. JAMA Health Forum. 2024;5(3):e240028-e240028. doi:10.1001/jamahealthforum.2024.0028