Landsman Introduces Bipartisan Effort to Protect Patients from Predatory Insurance Practices

Cincinnati, OH – Today, Congressman Greg Landsman (D-OH-01) and Congressman Bob Onder (R-MO-03) introduced bipartisan legislation to ensure patients with Medicare Advantage receive the health coverage promised by their insurance.

Medicare Advantage insurance companies typically require doctors and patients to get prior authorization before providing certain procedures and services. But increasingly, insurers are reversing those approvals after patients already received care, offering less coverage than what was originally approved, or refusing payments for services that did not require prior authorization.

In response, Congressman Landsman and Congressman Onder introduced the bipartisan Protecting Approved Care Act. The legislation will protect patients and doctors from Medicare Advantage insurance companies reversing coverage decisions or changing coverage after care was approved.

Under the Protecting Approved Care Act, if prior authorization is granted:

• The plan may not deny coverage based on lack of medical necessity.
• The plan may not reopen the determination, except for good cause or fraud.
• The plan may not change the billing code assigned to the claim to reduce payment except under limited exceptions.

If services do not require prior authorization:

• The service must be treated as if prior authorization was granted.
• The same protections apply: No denial of coverage after the fact.
• No downcoding to reduce payment.
• No reopening of determinations except for good cause or fraud.

Congressman Landsman:

“Even as health care costs rise, these insurance companies continue to take advantage of Americans by putting their business over patients. These predatory practices have to end. If coverage is approved, they need to keep their word.”

Congressman Bob Onder:

“As a physician, I know that when a plan approves a treatment, the doctor and the patient need to be able to count on it. Reaching back months later to claw back payment for care a plan already approved undermines that certainty and makes it harder for physicians to keep seeing their patients. This bill makes Medicare Advantage plans keep their word, and I’m glad to work with Rep. Landsman on it.”

Joel L. Mayerson, MD, Chair, American Academy of Orthopedic Surgeons Advocacy Council:

"As an orthopaedic surgeon, I applaud Rep. Onder and my fellow Ohioan Rep. Landsman for taking action to bring accountability and stability to the Medicare Advantage program. The AAOS is proud to support the Protecting Approved Care Act and looks forward to working alongside Congress to strengthen the prior authorization system for patients and physicians.” 

Read the bill text here.

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