[{"_1":2,"_109":-5,"_110":-5},"loaderData",{"_3":4,"_26":27},"root",{"_5":6,"_17":10,"_18":19,"_20":21,"_22":10,"_23":-5,"_24":-5,"_25":10},"user",{"_7":8,"_9":10,"_11":10,"_12":-5,"_13":-5,"_14":15,"_16":-5},"roles",[],"isAuthenticated",false,"isPremium","planName","subscriptionStatus","featureFlags",{},"insightsBudget","isDevelopmentHost","userPreferences",{},"recaptchaSiteKey","6LcvOJcUAAAAAHsB-gPGfGktcRlKpH7OTIU_dMTD","isImpersonating","impersonation","affiliateStatus","isFreedomPortal","routes/v2/article/layout",{"_28":29,"_30":31},"notFound",true,"relatedArticles",[32,75,87,98],{"_33":34,"_35":36,"_37":38,"_39":40,"_41":42,"_43":44,"_45":46,"_47":48,"_49":50,"_51":52,"_53":54,"_55":56,"_57":58,"_59":60,"_61":62,"_63":64,"_65":66,"_67":68,"_69":70,"_71":72,"_73":72,"_74":72},"mediaId",6159760,"mediaKeyId","5452631-8a86405ae5324665099f89b111b20621","parentId",5452631,"title","Lawmakers press plans on directories, 'ghost networks' and the need for apples-to-apples data","audioSeconds",10197,"startMs",3323000,"endMs",13520000,"viewUrl","/Search/View?dp=1&key=5452631-8a86405ae5324665099f89b111b20621&start=3323&end=13520","thumbnailUrl","https://assets.pipeline.soar.com/5452631-8a86405ae5324665099f89b111b20621/thumbnail_3323000.jpg","articleUrl","/articles/6159760/Lawmakers-press-plans-on-directories-ghost-networks-and-the-need-for-apples-to-apples-data","mediaUrl","https://secure.pipeline.soar.com/6159760-832e5e0ab8516858df2d8277cc055eff/orig.mp4?Expires=1770332850&Signature=CoPAaekZlZeR2LLpAEZ~bhqiNzPZl6L4dcT2ZLATDBWf0HB6BfsDtb6gI-6y0vps9MyHjwv915ETVRkD-iMq0U8E3gWK0gxtWSXza3g3ykrxM7OXAkwrIUY4CfIKE6j12bOh7IG-14aOcJTHwAX0bhCDukjpzwd5IQVHRw~iriFg2CLXNefha1EUzOfvMRwulq3tIqHsVnPovRlRNmLZ4BLTpzkj0y42gZ4QN5Es0Kz7aZRjR73PdkLSTjzZOVXXgXKaxYgsq5900ZukW~cd7F730bJadA2aVkhom0Myvq-ZSSG-9Cj7h6OVudnIfZ3TX1IpHxtvLDlmICH4f~kkTQ__&Key-Pair-Id=KUT5TJCACFTXG","author","U.S. House Committee on Ways & Means","date","2025-07-23T15:40:01.213Z","article","Lawmakers and witnesses told the House Ways and Means joint subcommittee hearing that inaccurate provider directories — so-called “ghost networks” — and limited public data hamper beneficiaries’ ability to choose plans and can result in unexpected out-of-network bills.

Brookings senior fellow Matthew Fiedler and Rep. Michael Burgess (questions) and Rep. Tom Bean (remarks) referenced personal and constituent experiences illustrating the problem. Dr. Brian Miller, a physician and witness, said he personally “incurred an $8,000 out-of-network medical bill because the provider directory was not up to date,” and recommended that the Medicare Plan Finder include a function, similar to the ACA marketplace, that lets beneficiaries check whether a given doctor or hospital is in a prospective plan’s network.

Rep. Michael Burgess (chair/commenter) and others said a legislative fix to require more accurate, frequently updated directories would protect beneficiaries. Representative Danny Davis and others urged an “apples-to-apples” comparison of MA and traditional Medicare costs and outcomes; Rep. Bean said he filed an “apples to apples” bill directing CMS to release fuller comparative data.

What witnesses suggested: Plan-level publication of provider-directory accuracy measures, searchable plan-finder tools that accept a beneficiary’s current provider names and return network status, and annual director-update requirements enforced by CMS. Brian Miller said making directories usable at point of sale would reduce surprise out-of-network encounters and enable oversight audits.

Committee follow-up: Members from both parties asked staff to examine the Real Health Providers Act (a bill introduced by members of the committee that would require annual provider-directory updates) and the Bean “apples-to-apples” data-release proposal. The hearing did not include a vote on either measure.

","mediaType","Video","parentTitle","Hearing on Medicare Advantage: Past Lessons, Present Insights, Future Opportunities","oneSentenceSummary","Members urged CMS and insurers to fix inaccurate provider directories and publish comparable data so beneficiaries can make informed choices; proposals included allowing plan-finder searches for a patient's current doctors and requiring annual directory updates.","taxTitle","Ways and Means: House Committee, Standing Committees - House & Senate, Congressional Hearings Compilation, Legislative, Federal","taxId",1828,"location","","headline","shortSummary",{"_33":76,"_35":36,"_37":38,"_39":77,"_41":78,"_43":79,"_45":80,"_47":81,"_49":82,"_51":83,"_53":84,"_55":56,"_57":58,"_59":85,"_61":62,"_63":64,"_65":86,"_67":68,"_69":70,"_71":72,"_73":72,"_74":72},6159764,"Witnesses defend supplemental benefits in Medicare Advantage while urging transparency on utilization",13813,1200000,15013000,"/Search/View?dp=1&key=5452631-8a86405ae5324665099f89b111b20621&start=1200&end=15013","https://assets.pipeline.soar.com/5452631-8a86405ae5324665099f89b111b20621/thumbnail_1200000.jpg","/articles/6159764/Witnesses-defend-supplemental-benefits-in-Medicare-Advantage-while-urging-transparency-on-utilization","https://secure.pipeline.soar.com/6159764-a4c660848e71545962f930b4b58da455/orig.mp4?Expires=1770332850&Signature=TyuinppGhpeGi1mit~~cEBlyvLLv3pTdFcwukLdeypPs1QQbzTlxnN96fPcM0QqLmedlQjKcrviWFF9pz3MNQBLFyEj7MeeAFGHg4gGrUyd-FdMZmjaV0rfa6~NvzsS3N6eCn1PulQuetXej~4YdCcp~wm2jsbCWWCTeqvTBMgWFZLKuR2nLPzpkwJW5eosWjp1-IeqTfungOjX~L2XZOwFP3eGUHBotTdc4ROHIDB1JhXGvnn1Iu38x~ItOYxd3dDAFLad76tbs~qpTFqOoubM2~g94o59y1KHSYMvegiATps8E673y3yi2LBqcB1-nIUvQgxUqBN958vjI5nlLwg__&Key-Pair-Id=KUT5TJCACFTXG","Several witnesses told the House subcommittees that supplemental benefits are a core reason many beneficiaries choose Medicare Advantage and that those benefits can reduce utilization and improve outcomes when targeted to high-need patients.

Dawn Maroney, CEO of Alignment Health Plan, described an instance where a data-flagged, high-risk member received a $30 meal delivery that averted a costly hospitalization. “When we sent him a $30 pizza instead of sending him to the hospital, it not only avoided an unnecessary $20,000 hospitalization, it built trust,” Maroney said.

Sachin Jain, president and CEO of SCAN, argued MA’s flexibility to cover integrated services — dental, vision, hearing, transportation and care coordination — helps lower out-of-pocket costs for beneficiaries who cannot afford supplemental Medigap plans. “Medicare Advantage helps fill those gaps,” Jain said, adding that MA often acts as a social-safety-net alternative for lower-income older adults.

Policy tension: Economists and oversight-focused witnesses warned that the extra spending on MA supplemental benefits is paid for in part by higher plan payments and could be inefficient if the dollars are not reaching beneficiaries. Brookings’ Matthew Fiedler said evidence suggests only part of additional MA payments is returned to enrollees as higher benefits; some is retained as profits or marketing.

Lawmakers asked for more utilization data on supplemental benefits. Rep. Terri Sewell and others noted CMS lacks comprehensive, public reporting on how often beneficiaries use supplemental benefits and which types deliver measurable health improvements.

Veterans and dual-eligibles: Rep. Doggett highlighted a concern about MA payments tied to dually eligible veterans receiving care from the VA, saying researchers estimate a potential multibillion-dollar misalignment over time. He and other members described pending legislation intended to allow the VA to recoup costs in some VA-delivered care scenarios.

What witnesses recommended: Increased transparency on supplemental-benefit utilization, better CMS reporting and targeted evaluation of which benefits demonstrably reduce medical spending or improve outcomes. Several witnesses asked Congress to preserve MA’s ability to innovate while tightening oversight to ensure supplemental dollars reach patient care.

","Plan executives and nonprofit plan leaders said supplemental benefits such as meals, transportation and integrated Part D coverage help beneficiaries, but analysts and lawmakers urged more transparent reporting on how those dollars are used.",{"_33":88,"_35":36,"_37":38,"_39":89,"_41":90,"_43":91,"_45":80,"_47":92,"_49":93,"_51":94,"_53":95,"_55":56,"_57":58,"_59":96,"_61":62,"_63":64,"_65":97,"_67":68,"_69":70,"_71":72,"_73":72,"_74":72},6159769,"Providers say Medicare Advantage prior authorization causes delays, rural strains",12327,2686000,"/Search/View?dp=1&key=5452631-8a86405ae5324665099f89b111b20621&start=2686&end=15013","https://assets.pipeline.soar.com/5452631-8a86405ae5324665099f89b111b20621/thumbnail_2686000.jpg","/articles/6159769/Providers-say-Medicare-Advantage-prior-authorization-causes-delays-rural-strains","https://secure.pipeline.soar.com/6159769-e6465690c07ce883f199fc4346ffe31e/orig.mp4?Expires=1770332850&Signature=iUtfxUmJhBbkjGm8Oz5bJS5wP4hzKej5dX3tnxaH1y~1-AkbV1u8ZxLu42YppMjNyA27UT4y6FChuWTaK8fISl-Tu3ofjcx-4tWPyZu82fiKSRKcFuMWOhQCJ821kllO2Tk5M5NHYbu4di9ohPz2nTlKDNvFfzcPpocW2jVRlppE6oaQaaxWoY8r1ISSQDRZxyvGwSAiQhoMvwgqui5MZuUGl8l3gDHPrUq2UKUsa-D9m~l3s1ImXce77n~eMpvHJFhxQ7quyYF8NAy~zog4aS7zhNK8TuTTXwCxJOdwEKfJs2UOZmK0WJ9AJfmFNhfgGYewpnnG~VcFWJrCwu6h2Q__&Key-Pair-Id=KUT5TJCACFTXG","Provider witnesses at the joint House hearing described growing operational strain from Medicare Advantage utilization-management practices and called for streamlined, electronic prior authorization processes.

David Basil, vice president of clinical quality for Avera Health, told the committee that his rural health system has seen a sharp rise in denials and authorization delays. “Our volume of care denials have more than doubled since 2022,” Basil said, adding that overturned denials and lengthy appeals processes impose large administrative workloads on facilities with limited staff.

Why it matters: Witnesses said prior-authorization delays can increase hospital length of stay, block timely discharge to post-acute care and leave hospitals holding higher costs. Basil described instances where MA plans downgraded inpatient stays to observation or refused payment for readmissions within 30 days even when unrelated to the initial admission.

Alignment Health Plan CEO Dawn Maroney said her company keeps prior-authorization denials below 2% by front-loading care coordination. “Approximately 95 to 97% of prior auths that come through the system are automatically approved at Alignment,” she said, describing care-navigator programs and early engagement for newly enrolled beneficiaries.

Witnesses from provider-sponsored plans and hospitals proposed a set of operational reforms: real-time electronic submission of clinical data from the electronic health record (EHR), clear point-of-care visibility into plan medical criteria, automating approvals for routine requests, and expanding tools that let clinicians submit complete documentation at the time of care. Johns Hopkins physician and testimony author Brian Miller urged “1-click submission of data in the electronic health record” and said automated approvals should be the default for well-documented, routine requests.

Several members highlighted rural impacts. Rep. Terri Sewell and others said small hospitals and rural clinics lack dedicated authorization teams and often must reassign clinical staff to appeals — work that detracts from patient care. Dr. Basil said extended waits for post-acute approvals can leave patients in acute beds and hamper transfers from rural hospitals to tertiary centers.

The committee discussed voluntary and regulatory steps to reduce burdens, including CMS and industry prior-authorization initiatives. Panelists differed on the role of AI: some witnesses argued it could speed approvals when programmed to approve routine requests, while others warned that AI trained on denial-first criteria could worsen access if left unchecked.

What’s next: Members asked for plan-level data on denial rates, overturn rates and average time to determination. Rep. Jan Schakowsky and others urged incorporating prior-authorization performance metrics into the public quality framework so beneficiaries and providers can compare plans. No formal rule changes were adopted at the hearing.

","Health system and physician witnesses told a House Ways and Means hearing that Medicare Advantage prior authorization volumes and denials are creating administrative burdens, delayed discharges and longer hospital stays, especially in rural areas.",{"_33":99,"_35":36,"_37":38,"_39":100,"_41":101,"_43":102,"_45":80,"_47":103,"_49":104,"_51":105,"_53":106,"_55":56,"_57":58,"_59":107,"_61":62,"_63":64,"_65":108,"_67":68,"_69":70,"_71":72,"_73":72,"_74":72},6159774,"House hearing spotlights alleged Medicare Advantage overpayments and proposed fixes",14045,968000,"/Search/View?dp=1&key=5452631-8a86405ae5324665099f89b111b20621&start=968&end=15013","https://assets.pipeline.soar.com/5452631-8a86405ae5324665099f89b111b20621/thumbnail_968000.jpg","/articles/6159774/House-hearing-spotlights-alleged-Medicare-Advantage-overpayments-and-proposed-fixes","https://secure.pipeline.soar.com/6159774-8f7103e0de6e724f5f16c8d8e92f4f43/orig.mp4?Expires=1770332850&Signature=aQvZgDK0quaiS3lNLUBuhIAg2wjZXDKtcK1h9RcFYOOB6wrStwteYwoRoKLJaRk6dc-4F170WbISRDvaGP2vlTunoGEEWg0BHdJMVryS2qG0E0COu6JfZlKhROHpWoXQAb5nutHO14Eo7PNi9IgBebiDKD2v1wYn9ADe9SDjtIwvVFgdtG23yPcRzjSncdz3XHTZ8iZ~Lmh0GQ4u7f4gVcMHGK~hovTnQjVJZzyn0AuhcbJKM-fpThgiPsp6VifzzVfmjqIUExh-CFZxpScK~CW~ID7DlSYYlQFruzpSUwXzAcSfwKTP1XqrZrh~stcQu1CiE0o~INVWM7mFwOvFwQ__&Key-Pair-Id=KUT5TJCACFTXG","A joint hearing of the House Ways and Means health and oversight subcommittees opened with members from both parties pressing for changes to how Medicare Advantage is paid, supervised and audited.

Rep. Lloyd Doggett, ranking member on the health subcommittee, told the panel the hearing presented “an opportunity to start paving a new bipartisan path toward fiscal responsibility,” and singled out what he described as “waste, fraud and abuse” in the program. Doggett cited nonpartisan estimates that Medicare Advantage (MA) payments exceed the cost of traditional Medicare by about 20% and said that disparity costs taxpayers tens of billions of dollars each year.

Why it matters: Members from urban and rural districts said overpayments to MA plans drive higher Part B premiums and reduce funding available for other Medicare services. Several witnesses pressed for specific technical corrections to the MA payment formula — including changes to risk adjustment and to how CMS accounts for more intensive diagnosis coding by MA plans.

Brookings Institution senior fellow Matthew Fiedler, a health economist who testified to the committee, summarized the program-level concern: “Covering a Medicare beneficiary under Medicare Advantage costs an estimated 20% more than covering the same person under traditional Medicare.” Fiedler said that discrepancy likely reflects a combination of coding intensity and favorable selection and recommended aligning MA payments more closely with the cost of comparable beneficiaries in traditional Medicare.

Lawmakers and witnesses described several possible reforms that surfaced during testimony: strengthening the coding-intensity adjustment CMS uses, adopting market- or insurer-specific adjustments, and revising benchmark formulas that determine plan payments. Fiedler said those changes could free federal dollars for either richer Medicare benefits or deficit reduction without reducing access to care for beneficiaries.

Legislation mentioned: Rep. Doggett said he and colleagues had introduced the bipartisan Prompt and Fair Pay Act to require MA plans to pay at least what traditional Medicare would have paid for covered services and to establish prompt-payment rules; he also described a Guard Veterans Healthcare Act to allow VA to bill MA plans when veterans receive care from the VA rather than have MA plans retain capitated payments. Both measures were discussed as proposals the committee should consider; no formal committee votes or markups were recorded at the hearing.

What witnesses recommended: Several witnesses urged CMS to adopt clearer, more enforceable adjustments to the risk-adjustment system and to improve the transparency of payments and plan coding practices. Fiedler and others said better specification of CMS’s coding-intensity methodology (and stronger enforcement) would reduce incentives for plans to generate higher risk scores through extra documentation rather than additional patient care.

Bottom line: Members from both parties framed MA reform as a way to preserve program benefits for seniors while protecting taxpayers. The hearing surfaced consensus on the need for stronger oversight and technical fixes to the payment system, but it produced no committee action during the session.

","A joint House hearing examined payments to Medicare Advantage plans, citing MedPAC estimates that MA payments exceed traditional Medicare by roughly 20% and lawmakers urged payment-system reforms and new oversight tools.","actionData","errors"]

Article not found

Lawmakers press plans on directories, 'ghost networks' and the need for apples-to-apples data

Witnesses defend supplemental benefits in Medicare Advantage while urging transparency on utilization

Providers say Medicare Advantage prior authorization causes delays, rural strains

House hearing spotlights alleged Medicare Advantage overpayments and proposed fixes