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Jayapal, DeLauro Urge President Biden, Secretary Becerra to Stop Medicare Advantage Organizations from Improperly Denying Care for Seniors

WASHINGTON – U.S. Representatives Pramila Jayapal (WA-07) and Rosa DeLauro (CT-03) sent a letter today to President Biden and U.S. Department of Health and Human Services (HHS) Secretary Becerra urging immediate action to stop Medicare Advantage Organizations (MAOs) from improperly denying care for seniors. The letter followed a report published by the Department of Health and Human Services Office of the Inspector General (HHS OIG) revealing that MAOs wrongly denied as many as 85,000 medical prior authorizations and 1.5 million payment requests. 

“It is concerning that MAOs are allowed to continue to administer care to seniors after demonstrated delays or refusals to cover medically-necessary care,” the lawmakers wrote. “The organizations administering care must be held to the same standard as medical professionals providing that care. Medical negligence by MAOs is dangerous and deadly and must be stopped.”

This was not the first documented evidence of bad faith actions by MAOs to put profits and their bottom line above proper care for our elderly citizens. Jayapal previously led members of Congress in another letter to Secretary Becerra and Centers for Medicare and Medicaid Services (CMS) Administrator Brooks-LaSure calling on them to end Medicare Advantage profiteering, in hundreds of billions of dollars of taxpayer dollars in wrongful overpayments were siphoned by these organizations.  DeLauro previously led members, including Jayapal, in a letter urging CMS to address overpayments and increase transparency in the Medicare Advantage program. 

Among the actions the lawmakers recommended President Biden and Secretary Becerra take to eliminate MAOs’ wrongful denial of care were:

  1. Issuing new guidance on MA prior authorization medical necessity reviews. Guidance should clearly state that MAOs cannot impose any additional clinical requirements outside of those required by traditional Medicare. 
  2. Increasing severity of enforcement actions on MAOs that improperly restrict patient care. These actions should include contract termination and prohibition of new contracts to ensure bad acting MAOs do not have the opportunity to harm any additional patients. 
  3. Undertaking rapid initiatives to address broader issues with MAOs including payment accuracy and predatory advertising. The current proposed rule to tighten regulations on MAO advertising must be strengthened by drastically limiting the marketing opportunities for MAOs and action must be taken to stop overpayment to MAOs.
  4. Stopping the ACO-REACH program and prevent traditional Medicare beneficiaries from facing the same care denials plaguing MA beneficiaries. This will prohibit MAOs from further interfering with seniors’ medical care through encroachment on traditional Medicare. 

A copy of the letter is available here.