The report recommends that CMS issue new guidance on MAO clinical criteria, update audit protocols, and direct MAOs to address vulnerabilities leading to errors. CMS concurred with all recommendations.
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.
Our case file reviews determined 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. Denied requests that meet Medicare coverage rules may prevent or delay beneficiaries from receiving medically necessary care and can burden providers. Although some of the denials that we reviewed were ultimately reversed by the MAOs, avoidable delays and extra steps create friction in the program and may create an administrative burden for beneficiaries, providers, and MAOs
Some Medicare Advantage Organization denials of prior authorization requests raise concerns about beneficiary access to medically necessary care. (2024, February 27). Office of Inspector General | Government Oversight | U.S. Department of Health and Human Services. https://oig.hhs.gov/reports/all/2022/some-medicare-advantage-organization-denials-of-prior-authorization-requests-raise-concerns-about-beneficiary-access-to-medically-necessary-care/
U.S. Department of Health and Human Services, & Grimm, C. A. (2022). Some Medicare Advantage Organization denials of prior authorization requests raise concerns about beneficiary access to medically necessary care. In U.S. Department of Health And Human Services Office of Inspector General (Report OEI-09-18-00260). https://oig.hhs.gov/oei/reports/OEI-09-18-00260.pdf
Testimony Before the United States House Committee on Energy and Commerce Subcommittee on Oversight and Investigations. “Protecting America’s Seniors: Oversight of Private Sector Medicare Advantage Plans”. June 28, 2022
Testimony Before the United States Senate Committee on Homeland Security and Governmental Affairs Permanent Subcommittee on Investigations. “Examining Health Care Denials and Delays in Medicare Advantage.” May 17, 2023
Alvarnas, J., MD. (2024, April 15). Amid rising complaints about prior authorization under Medicare Advantage, new rule leaves gaps. AJMC. https://www.ajmc.com/view/amid-rising-complaints-about-prior-authorization-under-medicare-advantage-new-rule-leaves-gaps
Jaffe, S. (2022, October 4). Nursing Home surprise: Advantage plans may shorten stays to less time than Medicare covers – KFF Health News. KFF Health News. https://kffhealthnews.org/news/article/nursing-home-surprise-medicare-advantage-plans-shorten-stays/
Morse, S. (n.d.). Medicare Advantage plans deny prior authorizations that meet Medicare approval, OIG says. Healthcare Finance News. https://www.healthcarefinancenews.com/news/medicare-advantage-plans-deny-prior-authorizations-meet-medicare-approval-oig-says
OIG dings Medicare Advantage plans for use of prior authorization. (2022, April 28). Fierce Healthcare. https://www.fiercehealthcare.com/payers/oig-dings-medicare-advantage-plans-use-prior-authorization
Sullivan, T. (2022, August 6). HHS OIG reviews prior authorization denials. Policy & Medicine. https://www.policymed.com/2022/08/hhs-oig-reviews-prior-authorization-denials.html
May, A. |. B. J. A. |. (n.d.). Medicare advantage Prior authorizations are often unnecessarily denied. https://www.healthleadersmedia.com/revenue-cycle/medicare-advantage-prior-authorizations-are-often-unnecessarily-denied
Improve Medicare Advantage reimbursements with payer contract management that puts payer rules in the hands of clinicians & billers.
