In a letter submitted to the House Energy and Commerce Oversight and Investigations Subcommittee for a hearing today, AHA called for greater congressional oversight to protect access to care for Medicare Advantage beneficiaries. The letter urges Congress to support legislation (H.R.3173/S.3018) to streamline MA plans’ prior authorization requirements; prohibit MA plans from using more restrictive medical necessity and coverage criteria than traditional Medicare; establish a provider complaint process and enforce penalties for plans that fail to comply with federal rules; and clarify states’ role in MA plan oversight. AHA also urges Congress to require MA plans to publicly report on standard performance metrics related to coverage denials, appeals and grievances; and CMS to conduct more and targeted audits for plans with a history of inappropriate denials. 

AHA last month urged swift CMS action to hold MA 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.

Officials from OIG, the Government Accountability Office and Medicare Payment Advisory Commission testified at today’s hearing. 
 

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