Watchdog Report Reaffirms Concerns With Fail First

Watchdog Report Reaffirms Concerns With Fail First

A new report by the Office of Inspector General at the U.S. Department of Health and Human Services (HHS) reaffirms concerns with a regulatory decision that undermines the health and well-being of America’s seniors.

In an abrupt reversal of long-standing policy, the Centers for Medicare & Medicaid Services (CMS) announced that Medicare Advantage health plans can impose “step therapy” requirements on patients who need drugs covered under Medicare Part B.

The new directive — which affects more than one-third of all Medicare beneficiaries — will force some patients to fail first on a medicine preferred by their insurance companies before they can receive the therapy prescribed by their doctors.

More than 230 patient and provider groups have warned the new policy “could put patients’ health at risk” and impose greater administrative burdens on physicians.

But what does this have to do with the HHS Inspector General? Well, in a new report, the independent watchdog reveals that patients are often wrongly denied care by health plans participating in the Medicare Advantage program. According to the report:

  • The “central concern” is that health plans may put profits before patients. The report notes “potential incentives” that encourage health plans to “inappropriately deny access to services and payment in an attempt to increase their own profit.”
  • Health plans routinely deny coverage, forcing patients to file appeals or forego the medical care they need. In fact, 75 percent of all coverage or payment denials issued by health plans were overturned at the first stage of the appeal process, which strongly suggests the insurance industry is taking a “deny first” approach to caring for America’s seniors.
  • Seniors face a “confusing and overwhelming” appeals process, which may explain why only 1 percent of coverage denials are actually appealed.
  • The often inaccurate denials of coverage by health plans are particularly worrisome for seniors who rely on Medicare Advantage and “may be especially burdensome for beneficiaries with urgent health conditions.”

These startling facts do not bode well for seniors, particularly as the Trump administration provides these same health plans new tools to restrict seniors’ access to prescription medicines.

And now UnitedHealth—the largest insurance carrier in the Medicare Advantage program—is rushing to impose the flawed fail first approach on millions of seniors starting next year. As the Society for Women’s Health Research cautioned in a recent letter, the current approach is flawed because it “lacks basic beneficiary protections and agency oversight that should be fundamental to any utilization management policy.”

The Trump administration should reverse course and withdraw this harmful policy. At the very least, it should not allow insurance companies to rush forward until basic safeguards are in place that ensure seniors aren’t wrongly denied the medicines they need.

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