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Federal investigators concluded in a report released Thursday that tens of thousands of people enrolled in private Medicare Advantage plans are denied the necessary care they should be covered each year.

Investigators urged Medicare officials to strengthen oversight of these private insurance plans that benefit 28 million older Americans, and called for more sanctions against plans with an inappropriate denial pattern.

Benefit plans have become an increasingly popular option among older Americans, offering customized versions of Medicare that are often less expensive and provide a wider array of benefits than traditional government-run program offerings.

Enrollment in Advantage plans has more than doubled in the past decade, and half of Medicare beneficiaries are expected to choose a private insurer over the traditional government program in the next few years.

The industry’s main trade group claims that people choose Medicare Advantage because it “provides better services, better access to care, and better value.” But federal investigators say there is troubling evidence that plans delay or even prevent Medicare beneficiaries from receiving medically necessary care.

new reportThe Department of Health and Human Services investigated from the office of the inspector general whether some services that were denied would likely be approved if beneficiaries had enrolled in traditional Medicare.

Investigators found that tens of millions of denials of both authorization and reimbursements were issued each year, and audits of private insurers showed evidence of “pervasive and persistent problems with improper denial of service and payments.”

The report reflects similar findings by office in 2018 It shows that private plans reverse about three-quarters of those rejected on appeal. Hospitals and doctors has been complaining for a long time It’s about insurance company tactics, and Congress is considering legislation that aims to address some of these concerns.

In its 430 denial review in June 2019, the OIG said it found repeated instances of denial of care for medical services, with coding experts and doctors reviewing identified cases as medically necessary and needed to be addressed.

Investigators estimate that there are 85,000 beneficiary requests for prior authorization for medical care, based on the finding that about 13 percent of denied claims should be covered by Medicare. Potentially inappropriately rejected in 2019.

Benefit plans also refused to pay legitimate claims, according to the report. About 18 percent of payments were declined despite compliance with Medicare coverage rules; this is an estimated 1.5 million payments for the whole of 2019. In some cases, plans ignored previous permits or other documents required to support payment.

Rosemary Bartholomew, who led the team working on the report, said these denials can delay or even prevent a Medicare Advantage beneficiary from receiving needed care. Only a small percentage of patients or providers said they tried to appeal these decisions.

“We are also concerned that beneficiaries may not be aware of the larger barriers,” he said.

Kurt Pauker, 87, who is a Holocaust survivor in Indianapolis and has complicating kidney and heart conditions, is enrolled in a Medicare Advantage plan sold by Humana.

Despite the advice of Mr. Pauker’s doctors, his family said that Humana repeatedly refused an inpatient permit after he was hospitalized, sometimes too healthy to benefit, and sometimes too sick.

After undergoing hip surgery last March, his family told Mr. Pauker that he was not fit for inpatient rehabilitation but would be sent back to a skilled care center to recover.

The family said that during her previous stay at a gifted care center, she received very little in the form of physical or occupational therapy. So far, she has lost her appeal, and her relatives have chosen to pay her maintenance costs privately while continuing to pursue their case.

People “should know what they’re giving up,” says David B. Honig, a health lawyer and Mr. Pauker’s son-in-law. People who signed up for Medicare Advantage said they were giving up the right to decide what was medically necessary, rather than for the insurer to decide.

Reporting strong earnings Wednesday, Humana said it could not comment specifically on Mr Pauker’s case, citing confidentiality rules. However, the insurer noted that standards set by the Centers for Medicare and Medicaid Services must be followed.

“While each member’s experience and needs are unique, we strive to provide health coverage that is consistent with what we believe CMS will require in each case, and we support our members in reaching their best health,” Humana said in a statement. Said.

Medicare officials said in a statement that they are reviewing the findings to determine the next appropriate steps, and plans found to have repeated violations will be subject to increased penalties.

Officials said the agency is “committed to ensuring that people with Medicare Advantage have timely access to medically necessary care.”

The federal government pays private insurers a flat amount per Medicare Advantage patient. The insurer makes a profit if the patient’s choice of hospital or doctor is limited and is encouraged to seek cheaper but effective services.

Under traditional Medicare, hospitals and doctors may be encouraged to overtreat patients as they get paid for every service and test performed. But the fixed payment for private plans provides “potential incentives for insurers to deny access to services and payments in order to increase their profits.”

President-elect of the American Medical Association, Dr. Jack Resneck Jr. said denials of the plans are becoming commonplace. The organization is aggressively lobbying lawmakers to introduce stricter rules.

Dr. Resneck said the pre-authorization, aimed at limiting very expensive or unproven treatments, has “expanded far beyond its original purpose.” “When patients can’t get approval for a new prescription, many don’t fill it out and never tell the doctor,” he said.

Some doctors said appeals unfairly burden patients and often take up valuable time.

A cancer specialist who has served as CEO of Carolina Blood and Cancer Care and president of the Community Oncology Alliance, Dr. “We can sometimes reverse that,” said Kashyap Patel. But he added that efforts to “fight like a hawk” to gain approval for the care he’s recommending have resulted in less time caring for patients.

The most common denials by researchers included those for imaging services such as MRI and CT scans. In one case, an Advantage plan refused to approve a follow-up MRI to determine whether a lesion was malignant after it was detected by a previous CT scan because the lesion was too small. The plan reversed its decision after an appeal.

In another case, a patient had to wait five weeks before authorizing him to have a CT scan to evaluate his endometrial cancer and determine a course of treatment. This type of delayed care can adversely affect a patient’s health, the report said.

However, Advantage plans also declined requests to send patients recovering from a hospital stay to a skilled care center or rehabilitation center when doctors determined that these locations were more appropriate than sending a patient home.

Researchers found that a patient with bedsores and a bacterial skin infection was denied transfer to a skilled care center. A high-risk patient recovering from surgery to repair a broken femur was denied admission to the rehabilitation center, although doctors said the patient should be under a doctor’s supervision.

In some cases, the researchers said Medicare guidelines need to be clarified—such as whether a plan would require the patient to have X-rays before receiving an MRI.

Plans can use their own clinical criteria to decide whether a test or service should be reimbursed, but they must offer the same benefits as traditional Medicare and cannot be more restrictive in paying for care.

Investigators urged Medicare officials to strengthen oversight of Advantage plans and provide consumers with “clear, easily accessible information about serious violations.”