Sunday, May 8, 2022
The Inspector General of HHS recently released this report, Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care.
Here's the OIG explanation why they did the study:
A central concern about the capitated payment model used in Medicare Advantage is the potential incentive for Medicare Advantage Organizations (MAOs) to deny beneficiary access to services and deny payments to providers in an attempt to increase profits. Although MAOs approve the vast majority of requests for services and payment, they issue millions of denials each year, and CMS annual audits of MAOs have highlighted widespread and persistent problems related to inappropriate denials of services and payment. As Medicare Advantage enrollment continues to grow, MAOs play an increasingly critical role in ensuring that Medicare beneficiaries have access to medically necessary covered services and that providers are reimbursed appropriately.
What the OIG found shows that "MAOs sometimes delayed or denied Medicare Advantage beneficiaries' access to services, even though the requests met Medicare coverage rules. MAOs also denied payments to providers for some services that met both Medicare coverage rules and MAO billing rules." They also found that 13% of denied prior authorizations met the coverage rules and that additionally some denials were made based on lack of documentation but OIG found sufficient documentation had been provided. 18% of payment request denials met the Medicare coverage rules.
Here are their recommendations
Our findings about the causes and circumstances under which MAOs denied prior authorization or payment for requests that met Medicare coverage and MAO billing rules provide an opportunity for improvement to ensure that Medicare Advantage beneficiaries have timely access to all necessary health care services, and that providers are paid appropriately. Therefore, we recommend that CMS:
issue new guidance on the appropriate use of MAO clinical criteria in medical necessity reviews;
update its audit protocols to address the issues identified in this report, such as MAO use of clinical criteria and/or examining particular service types; and
direct MAOs to take additional steps to identify and address vulnerabilities that can lead to manual review errors and system errors.
The full report is available here.