Medicare Advantage Enforcement Lapses: Concerns Raised Over Network Gaps and Patient Harm

Title: Despite Complaints of Gaps in Medicare Advantage Networks, Enforcement is Rare

In a startling revelation, it has come to light that federal enforcement regarding complaints about gaps in Medicare Advantage networks is remarkably rare. The Centers for Medicare & Medicaid Services (CMS) oversees these privately-run plans, but documents obtained by KFF Health News reveal that the agency rarely takes action against insurers who fail to meet network adequacy standards.

Despite the dire consequences of such failures, which can lead to harmful delays or even denial of care, CMS has only taken enforcement actions in an astonishingly small number of cases. The news highlights a concerning lack of accountability and transparency within the Medicare Advantage system.

Medicare Advantage plans have become increasingly popular, with over 54% of eligible Americans opting for these private plans. However, the reality is that federal requirements dictate that such plans must include a minimum of 29 types of healthcare providers and facilities. The agency checks compliance every three years or when complaints arise.

In shocking news, KFF Health News obtained letters from CMS to only five insurers from 2016 to 2022 after seven of their plans failed to meet these network requirements. These gaps can have devastating consequences for beneficiaries who may be forced to travel significant distances to find contracted providers.

Federal officials are aware of the situation but choose not to take action, leaving patients in limbo and vulnerable to potential harm. This lack of enforcement further exacerbates the already complex problem of healthcare access.

Experts point out that this lack of accountability undermines patient trust in the system, warning that it could lead to poor health outcomes or even loss of life.

Source: www.cbsnews.com