The Biden administration on Tuesday unveiled a new rule aimed at reining in privatized Medicare Advantage plans, which have drawn growing federal scrutiny for denying coverage claims en masse—sometimes using artificial intelligence—and overbilling the government to the tune of tens of billions of dollars per year.
But the proposal could soon be fed through the buzzsaw of the incoming Trump administration, which is likely to have an outspoken Medicare Advantage supporter, Mehmet Oz, at the helm of the Centers for Medicare and Medicaid Services (CMS).
Biden's CMS said in a fact sheet released Tuesday that the new rule would ensure MA companies make enrollees aware of their right to appeal coverage denials. CMS pointed to data showing that MA plans, which now cover more than half of the Medicare-eligible population, "overturn 80% of their decisions to deny claims when those claims are appealed."
"These data also show that a low percentage of denied claims are appealed, meaning many more could potentially be overturned by the plan if they were appealed," CMS added.
The rule would also look to constrain MA plans' deceptive marketing practices and "use of inappropriate prior authorization." Prior authorization is a byzantine process under which providers must demonstrate that a proposed treatment is medically necessary before the insurer will cover it.
"The big question, of course, is what will the Trump administration do with these rules? Will they side with patients needing treatment or care-denying big insurers?"
Robert Weissman, co-president of the consumer advocacy group Public Citizen, welcomed the new rule as a "common-sense" measure that would "limit" some of the damage inflicted by MA plans, which are notorious for denying patients necessary care.
"The big question, of course, is what will the Trump administration do with these rules? Will they side with patients needing treatment or care-denying big insurers?" Weissman continued. "Unfortunately, despite its populist pretensions, there's every reason to expect the Trump administration to block these proposed rules from moving forward. Dr. Mehmet Oz, Trump's nominee to run the Centers for Medicare and Medicaid Services, is a major proponent of expanding privatized Medicare, with nary a worry about privatized Medicare's rampant abuses and rip-offs of taxpayers."
Sen. Ron Wyden (D-Ore.), chair of the Senate Finance Committee, vowed Tuesday that he will "be watchdogging the incoming Trump administration to ensure there is no backsliding on these critical consumer protections and coverage improvements."
Oz, a long-time television personality known for hawking unproven treatments, has been characterized as a "shill" for MA, a program funded by taxpayers and run by for-profit insurance companies.
As recently as August, Oz boosted Medicare Advantage on his YouTube account, as New York magazine reported earlier this week:
In August, Dr. Mehmet Oz's official YouTube account posted a video titled "Get $0/Month Medicare Coverage: What You Need to Know," in which Oz lays a sales pitch on his viewers. "Which of these items can you get for zero dollars?" he says, pointing to images of a coffee cup, a pack of gum, and a newspaper, as if quizzing a toddler on the pictures in a children’s book. "Or how about a health insurance plan?" he says. If you've ever watched daytime television, you know how the next part goes: Oz reveals he was, indeed, talking about the health insurance plan, and the studio audience erupts into applause. He then brings out an insurance agent to paint a rosy portrait of Medicare Advantage before ending with a call to action, encouraging any seniors in the audience to call in to a special phone number or visit a website to learn more and enroll.
During his 2022 bid for a U.S. Senate seat, Oz campaigned on a proposal he called "Medicare Advantage for All"—while owning stock in UnitedHealth Group, the nation's largest MA insurer.
Oz's support for Medicare Advantage aligns with the Project 2025 agenda, which calls for making MA the default enrollment option for U.S. seniors—an existential threat to traditional Medicare. Such a sweeping change would hugely benefit UnitedHealth and other private insurance giants.
"Project 2025's plans for Medicare, seconded by Dr. Oz, will end Medicare as we know it, and leave seniors to the tender mercies of dishonest and debased private insurance plans," The American Prospect's Robert Kuttner warned Tuesday. "What's insidious is that none of these changes require legislation. The best we can hope for is that the sunlight of exposure of these schemes will act as a disinfectant."
