Medicare Advantage, the increasingly popular plans run by insurance companies that often offer dental and vision coverage and other perks beyond traditional Medicare B, are coming under scrutiny.

U.S. Sen. Richard Blumenthal, in particular, is concerned about what he sees as higher denials of treatment that then must be appealed by patients, at least partly caused by increasing use of artificial intelligence.

While as many as 80% of appeals are granted, too many patients don’t file appeals and go without needed treatment, he said.

“Abuses related to Medicare Advantage are probably one of the most significant failings of our health care system right now,” Blumenthal said. “I have an investigation ongoing as chairman of the Permanent Subcommittee on Investigations.”

“We will be producing a report probably in the next couple of months that will detail some of the profound flaws and failings in the performance by major insurers,” Blumenthal said. “Their abuses are deeply troubling and highly costly, causing both patients suffering and financial loss but also extraordinary expense to taxpayers.”

According to a report by Becker’s Healthcare, a number of hospitals and health care systems are beginning to refuse to take Medicare Advantage plans as coverage for patients.

“Among the most commonly cited reasons are excessive prior authorization denial rates and slow payments from insurers,” Becker’s reported. “Some systems have noted that most MA carriers have faced allegations of billing fraud from the federal government and are being probed by lawmakers over their high denial rates.”

None of the health care systems surveyed in Connecticut, including Hartford HealthCare, Yale New Haven Health, Trinity Health of New England and Nuvance Health, are refusing Medicare Advantage plans.

Blumenthal said the insurance companies review prior authorizations for treatment and are “clearly denying treatment in cases where it is merited under Medicare rules. They’re supposed to follow Medicare rules. A lot of the denials are determined by AI algorithms without oversight by treating physicians.”

Blumenthal said a 2021 study found 2 million denials, only 11% of which were appealed. Of those appealed, 80% of the denials were overturned. “People often accept them because of the burden and costs of appealing,” he said.

“So something is definitely and deeply wrong with their prior authorization determinations,” he said.

“We do see a lot of those (appeals) in our office and assist consumers with those appeals in our office,” said acting state Healthcare Advocate Sean King.

“And we also get frequent complaints about commercial insurance, so it’s hard to say whether the numbers … are completely out of line with the prior authorization, utilization review processes and other types of health plans or if it’s something that’s more unique to Medicare Advantage.”

Medicare Advantage takes the place of Medicare B, which covers physician services, but clients must still pay their Medicare B premiums. Advantage also often takes the place of Medicare D, which covers prescriptions.

Medicare Advantage also may limit the doctors an enrollee may see without paying higher costs, depending on who is in the insurers’ network.

“It has its upsides and its drawbacks, so Medicare Advantage plans have been able to provide coverage of things like dental care, for example, that people can’t get under Medicare fee for service, and they’re able to structure their plans in a way that minimizes cost sharing for some people,” King said.

“There’s a reason why people are drawn to them is because they typically can save money in some way or another without spending more than they normally would on Medicare fee for service,” he said. “But the downside, the overall trend is that Medicare Advantage tends to be effective for seniors who are on the healthier side.”

Blumenthal said only a small number of insurance companies enroll most of the Medicare Advantage clients.

“UnitedHealthcare and Humana together account for about 46% of them,” Blumenthal said. “And then there are a handful of others: Blue Cross Blue Shield, CVS Health, Kaiser Permanente.”

Another issue is that insurers have overcharged Medicare by exaggerating enrollees’ health conditions, Blumenthal said. “There are estimates that Medicare Advantage insurers have overbilled the Medicare program by $12 billion in 2020 alone,” he said.

According to the Better Medicare Alliance, which advocates for Medicare Advantage, 51% of all people with Medicare, or 32 million, have opted for Advantage plans.

“We are in favor of modernizing and streamlining utilization management to improve patient access,” said Susan Reilly, spokeswoman.

“We’ve supported the Improving Seniors’ Timely Access to Care Act, which would require MA plans to establish electronic prior-authorization standards,” she said. “And then we’re also very much in favor of requiring health plans to provide beneficiaries with clear and accessible information about what their coverage policies are, the requirements for plan communication and enrollment tools.”

She added, “We very much support transparency and clear understandable guidelines for seniors and people with disabilities who choose Medicare Advantage.”

Reilly said Medicare Advantage is affordable for people, many of whom live on low or fixed incomes. She said enrollees report saving $2,400 annually on out-of-pocket costs compared to fee-for-service Medicare.

“It’s not just Medicare Advantage that is using prior authorization,” she said. “It’s traditional fee for service that’s also using some prior authorizations. And there are studies that show that it improves the outcomes and affordability.”

She said she sees choice as important for people. “There’s not a one-size-fits-all, and seniors should have all the information they need and a clear and transparent way to make the decision that’s best for their health,” she said.

Reilly said 30% of Medicare Advantage plans in 2024 offered benefits for the chronically ill and a majority offered telehealth benefits as well, “with average monthly premiums less than $20 a month, which is significant because Medicare Advantage serves an overwhelmingly significant number of minorities and people living in underserved communities.”