A Victory for Outpatient Therapy Highlights the Need for Ongoing Reform

January 13, 2025-- As a new session of Congress begins, the ongoing oversight and reform of Medicare Advantage (MA) plans are critical as concerns grow about overpayments, care denials, and the use of AI in coverage decisions. Pressure to reform MA is at an all-time high and providers like United HealthCare (UHC) are seeing increased scrutiny. 

In response to growing pressure, UHC has recently changed its prior authorization rules, allowing providers to immediately start treatment for patients needing PT, OT, or SLP services! This means better and faster access to essential care for patients and decreased administrative burden for providers. This is a win for the tireless advocacy groups calling for more accountability for MA.

Delays and denials of care that affect the patients continue to provide concern and a challenge to the providers despite recent progress in curbing wasteful spending and prior authorization abuses. The American Medical Association and other stakeholders have criticized the excessive and unjustified use of prior authorization as a cost-control measure a recent MedPage Today article titled “Do the New CMS Rules on Prior Authorization Go Far Enough?” by Joyce Frieden (January 7, 2025), provider associations such as the American Medical Association (AMA) remain frustrated. The article states:

“The AMA agrees that prior authorization is still a big problem,” AMA President Bruce Scott, MD, said in a phone interview. “I think there’s a growing awareness across health systems that [prior authorization] is overused, unjustified, and needs to be right-sized,” he said. “Patients are becoming increasingly aware of this overused blunt cost-control process by insurance companies. As a result, there is anger that’s building and frustration among physicians that has grown as well.”

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Additional information can be found in several recent publications:

A recent Kiplinger article titled “Problems with Medicare Advantage Plans Keep Mounting” by Elaine Silvestrini (Jan. 4, 2025), states: “While most enrollees are satisfied with their plans, MA faces mounting criticism for denying and delaying some needed care while costing taxpayers billions more than government-run, so-called fee-for-service, traditional Medicare.”

“Senate Subcommittee Report Details Medicare Advantage Coverage Denials” (October 24, 2024),  in October 2024 Senator Richard Blumenthal (D-CT), Chair of the U.S. Senate Permanent Subcommittee on Investigations, released a 54-page report regarding its ongoing investigation of Medicare Advantage plans.

Most recently, the Journal published an article titled “UnitedHealth’s Army of Doctors Helped It Collect Billions More From Medicare” by Christopher Weaver, Anna Wilde Mathews, and Tom McGinty (December 29, 2024) “analysis found sickness scores increased when patients moved from traditional Medicare to Medicare Advantage, leading to billions of dollars in extra government payments to insurers”. 

As a new administration takes office, practices that prioritize profits over patient care should be an ongoing focus. Bipartisan support for reform underscores the need for a Medicare program that balances cost efficiency with access to necessary care.

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