Medicare beneficiaries' claims wrongfully delayed, rejected

Federal audit reports have found numerous instances of Medicare health plans improperly rejecting medical service claims, unjustly limiting coverage on prescription drugs and unfairly delaying patient access to care, according to The New York Times.

Practices that potentially harm beneficiaries by delaying or denying access to care or by providing deficient care are fined and penalized by Medicare officials.

Insurers that have been penalized for violations include:

  • Aetna, which was fined $500,000 for "widespread and systemic failures" of managing prescription drug benefits for Medicare patients.
  • Geiseger Health Plan in Pennsylvania, which faced fines of $184,000 for restricting access to certain prescription drugs.
  • Tufts Health Plan in Massachusetts, which was fined $137,700 for eight serious compliance violations.
  • Moda Health in Oregon, which had to pay $312,300 for a variety of violations regarding drug benefits, coverage decisions and the handling of consumer complaints.

SummaCare in northern Ohio and CalOptima — a nonprofit health system created by Orange County, Calif. — are currently banned from enrolling new Medicare customers until federal officials are satisfied deficiencies have been corrected.

Numerous other providers have also been penalized in the past year for violations such as failing to provide adequate rationale for coverage denial, failing to consider clinical information provided by physicians, failing to inform patients of appeal rights, improperly rejecting prescription drug claims and failing to meet deadlines for decisions about medical care coverage, drugs and devices.

 

 

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