The AHA today urged the Centers for Medicare & Medicaid Services to “take swift action to hold Medicare Advantage plans accountable for inappropriately and illegally restricting beneficiary access to medically necessary care,” citing in part a recent report from the Department of Health and Human Services’ Office of Inspector General that found an estimated 13% of prior authorization denials and 18% of payment denials should have been granted.

“Inappropriate and excessive denials for prior authorization and coverage of medically necessary services is a pervasive problem among certain plans in the MA program,” AHA wrote. “This results in delays in care, wasteful and potentially dangerous utilization of fail-first imaging and therapies, and other direct patient harms. In addition, they add financial burden and strain on the health care system through inappropriate payment denials and increased staffing and technology costs to comply with plan requirements. … The findings of the HHS-OIG report, as well as the broader experience of MA beneficiaries, hospitals, and health systems, clearly indicates that greater oversight of MA plans is needed to ensure appropriate beneficiary access to care.”

AHA recommended CMS take certain steps to increase MA plan oversight, improve patient access to care and address the issues raised in the OIG report. It also requested a meeting with CMS to further discuss these concerns.  
AHA calls for task force to investigate False Claims Act violations 
In a separate letter, AHA urged the Justice Department to establish a task force to conduct False Claims Act investigations into commercial health insurance companies that are found to routinely deny patients access to services and deny payments to health care providers. 
“It is time for the Department of Justice to exercise its False Claims Act authority to both punish those [Medicare Advantage Organizations] that have denied Medicare beneficiaries and their providers their rightful coverage and to deter future misdeeds,” AHA told the agency. “… And it is time for the Civil Division to focus more directly on the commercial insurers who commit this fraud. The AHA therefore urges you to create a ‘Medicare Advantage Fraud Task Force’ to investigate those MAOs that are failing to live up to the commitments they make to the federal government and the Medicare beneficiaries they have been entrusted to serve.” 
For more on the issue, see the recent AHA Advancing Health podcast, which examines how commercial insurers are impacting patient care through their policies. 

Related News Articles

The Centers for Medicare & Medicaid Services Sept. 26 released premium and cost-sharing information for Medicare Advantage and Part D prescription drug…
The Health and Human Services Office of Inspector General Aug. 28 released a strategic plan to align its audits, evaluations, investigations and…
In an Aug. 28 letter to House sponsors, the AHA voiced support for the GOLD Card Act of 2023 (H.R. 4968) that would exempt qualifying providers from prior…
Effective Aug. 27, the Joint Commission will eliminate or consolidate over 200 more accreditation standards in its hospital and other accreditation…
A bipartisan group of 233 representatives and 61 senators called on the Centers for Medicare & Medicaid Service to enhance its proposal to streamline…
AHA May 17 shared with the Homeland Security and Governmental Affairs Permanent Subcommittee on Investigations its concern that some MA plans inappropriately…