Medicare Advantage documents
Credit: designer491/Getty Images Plus

An influential group of healthcare providers is calling on the Department of Justice to investigate Medicare Advantage organizations that have been found wrongly denying services to beneficiaries. 

The American Hospital Association issued the plea in a letter dated Thursday to Brian Boynton, acting assistant attorney general of the Civil Division at the Department of Justice. The letter is in response to a federal study that found that MAOs often improperly denied or delayed services — even though the requests met Medicare coverage rules — in order to increase profits.

Post-acute facilities were among the healthcare services often involved in denials that met Medicare coverage rules, the report found. 

Medicare Advantage penetration has exceeded 40% in some long-term care markets, with rapid additional growth projected almost universally in many areas.

“It is time for the Department of Justice to exercise its False Claims Act authority to both punish those MAOs that have denied Medicare beneficiaries and their providers their rightful coverage and to deter future misdeeds,” Melinda Hatton, general counsel for the association, wrote in the letter.

“This problem has grown so large — and has lasted for so long — that only the prospect of civil and criminal penalties can adequately prevent the widespread fraud certain MAOs are perpetrating against sick and elderly patients across the country,” she added. 

Hatton argued that the agency has previously highlighted the Civil Division’s False Claims Act priorities, which include schemes that take advantage of elderly patients by providing them poor or unnecessary healthcare. She said this situation “falls squarely within [the division’s] priorities.”

“Seniors are being regularly refused vital medical services, and the Department is well-equipped to use its sophisticated anti-fraud tools to go after this persistent misconduct by certain MAOs,” Hatton wrote in calling for an investigation. 

“[Conducting an investigation] will ensure that our oldest Americans get the care they need under Medicare Advantage, and commercial insurers can no longer take massive amounts of federal dollars while denying necessary services,” she concluded.