A recent survey of Medicare Advantage enrollees found 13% had a claim or pre-authorization request denied as the program has gotten scrutiny over its prior authorization practices.
The survey, released Monday by the online insurance marketplace eHealth, also found that 67% of respondents chose MA over Medigap due to concerns over its affordability. The MA market has become an increasingly lucrative one for insurers, as projections expect enrollment to surpass traditional Medicare in the coming years.
“As demonstrated in this report, we found that a striking majority of Medicare Advantage enrollees are satisfied with their plans,” the survey said.
EHealth’s survey of more than 2,800 MA enrollees last month showed that a large majority (77%) did not have their claims or prior authorization requests denied, while 10% did not know and 13% reported they did have rejections.
Of the 13% who were denied coverage, 3% said they could not get a specific drug and 2% were for coverage visits.
“Those who experienced a self-reported denial of coverage include many who were declined for things like dental and vision care, which aren’t typically covered by Medicare,” the survey report said.
In addition, 43% of respondents who did have a claim or prior authorization request denied say their plan told them the claim was excluded from coverage. Another 15% said coverage was denied because the service wasn’t medically necessary.
But 15% of respondents who had a claim or request denied said that the insurer eventually paid it later.
The findings come amid increased scrutiny of MA insurers’ prior authorization practices. A report from the Department of Health and Human Services’ Office of Inspector General that analyzed 250 prior authorization denials and 250 payment denials from MA plans found the denials were sometimes for services that met Medicare coverage requirements.
For instance, 13% of prior authorization denials and 18% of payment declines were for services Medicare should cover.
The report comes as some lawmakers have criticized the MA program for driving up Medicare costs due to tactics to game risk adjustment scores and gain higher bonus payments.
EHealth’s report, however, showed that MA remains a very popular program with seniors. It found that 88% of respondents were satisfied with their coverage, and 63% were very satisfied.
One of the key benefits for the program is lower costs compared with Medigap plans as 67% of seniors said they chose MA because Medigap, which pays for supplement benefits not covered by traditional Medicare, was too expensive. Another 25% signed up with MA because Medigap did not offer drug coverage.