Creator: Patrick Connole
Bipartisan Bill Says No Way to ‘Predatory’ MA Coverage
Reps. Landsman (D-Ohio) and Onder (R-Mo.) wrote a bill to ensure MA plan holders don’t get shortchanged on coverage due to prior authorization practices.
Reps. Greg Landsman (D-Ohio) and Bob Onder (R-Mo.) have introduced bipartisan legislation to ensure patients with Medicare Advantage (MA) receive the health coverage promised by their insurance, tying the issue into the way some insurers utilize prior authorization in hindsight.
“MA insurance companies typically require doctors and patients to get prior authorization before providing certain procedures and services,” the press statement said. “But increasingly, insurers are reversing those approvals after patients already received care, offering less coverage than what was originally approved, or refusing payments for services that did not require prior authorization.”
In response, Landsman and Onder have unveiled their “Protecting Approved Care Act” that they said will protect patients and doctors from MA insurance companies reversing coverage decisions or changing coverage after care was approved.
The legislation would do the following.
If prior authorization is granted:
The plan may not deny coverage based on lack of medical necessity.
The plan may not reopen the determination, except for good cause or fraud.
The plan may not change the billing code assigned to the claim to reduce payment except under limited exceptions.
If services do not require prior authorization:
The service must be treated as if prior authorization was granted.
The same protections apply: No denial of coverage after the fact.
No downcoding to reduce payment.
No reopening of determinations except for good cause or fraud.
Read the bill text here.
Comments or questions? Contact Patrick Connole at pconnole@parkplacelive.com.
