OIG: CMS should address inappropriate Medicare Advantage plan denials

The Centers for Medicare & Medicaid Services should enhance its oversight of Medicare Advantage organization contracts and address persistent problems related to inappropriate denial of services and payment, the Department of Health and Human Services’ Office of Inspector General said in a report yesterday. When beneficiaries and providers appealed preauthorization and payment denials, MA organizations overturned 75 percent of their own denials between 2014 and 2016, OIG found. During the same period, independent reviewers at higher levels of the appeals process overturned additional denials in favor of beneficiaries and providers. “The high number of overturned denials raises concerns that some Medicare Advantage beneficiaries and providers were initially denied services and payments that should have been provided,” OIG said. “This is especially concerning because beneficiaries and providers rarely used the appeals process, which is designed to ensure access to care and payment.”