Federal Investigators Find Medicare Advantage Plans Too Often Deny, Delay Needed Care

“These denials can delay or prevent beneficiary access to medically necessary care; lead beneficiaries to pay out of pocket for services that are covered by Medicare; or create an administrative burden for beneficiaries or their providers who choose to appeal the denial,” the report notes. “These denials may be particularly harmful for beneficiaries who cannot afford to pay for services directly and for critically ill beneficiaries who may suffer negative health consequences from delayed or denied care.”

Denying needed care is not the best approach. The best care is the least expensive care. Optimal medical therapy for cardiometabolic disease dramatically improves clinical outcomes while reducing healthcare costs. Imaging studies like MRI or CT scanning are among the most frequently denied,

The best imaging decisions can reduce cost. Your primary care cardiometabolic team can order coronary CT angiography first for patients with chest pain or suspected coronary artery disease. It is a very accurate test to detect blockages and determine cholesterol plaque characteristics. That test only costs $401 and always involves a coronary calcium score first. If the calcium score is over 100, risk of heart attack is elevated and the patient needs optimal medical therapy (OMT). No further testing may be necessary. Invasive heart catheterization costs $2549. If the patient has chest pain, and you want to rule out left main coronary disease, the CT coronary angiogram can do that very accurately, and invasive heart artery catheterization is not necessary. Your primary care team can order the coronary CT angiogram and begin OMT. That is a much less expensive approach with better outcomes. The best care is less expensive care. Why wouldn’t you use that approach and make your Medicare Advantage program more successful?