OIG report: Medicare Advantage Organization denials of prior authorization requests raise concerns about access to medically necessary care

A recent report by the Office of Inspector General (OIG) found that some Medicare Advantage Organizations (MAOs) 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.

MAOs denied authorization requests when they did not have enough documentation to support approval, yet OIG reviewers found that the existing beneficiary medical records were sufficient to support the medical necessity of the services.

Imaging services, stays in post-acute facilities, and injections were three prominent service types among the denials that met Medicare coverage rules.

The OIG made three recommendations to the Centers for Medicare & Medicaid Services (CMS) as a result of these findings, including:

·????????Issue new guidance on appropriate use of MAO clinical criteria in medical necessity reviews

·????????Update audit protocols to address issues identified in the report, including MAO use of clinical criteria and/or examining particular service types

·????????Direct MAOs to take steps to identify and address vulnerabilities that may lead to manual review errors and system errors

CMS concurred with all three recommendations.

Contact ATTAC Consulting Group?to learn how your organization can implement compliant prior authorization processes and be audit-ready.?