The Centers for Medicare & Medicaid Services should take steps to prevent Medicare Advantage organizations from denying coverage and payment for medically necessary care, the Department of Health and Human Services’ Office of Inspector General advised yesterday. 

OIG reviewed a random sample of prior authorization and payment denials by 15 large MA organizations in 2019, and found 13% of coverage denials met Medicare coverage rules and 18% of payment denials met Medicare coverage and MA billing rules. The report describes the avoidable delays, extra steps, and administrative burden caused by inappropriate health plan denials and illustrates the negative impact on patient care and access through a series of case examples. 

“Denied requests that meet Medicare coverage rules may prevent or delay beneficiaries from receiving medically necessary care and can burden providers,” OIG said. 

The report recommends CMS issue guidance on the appropriate use of MAO clinical criteria in medical necessity reviews; update its audit protocols to address the identified issues; and direct MAOs to take additional steps to address vulnerabilities that can lead to manual and systemic review errors. 

AHA said the findings “confirm — and provide data and real-life examples — of the harm that certain commercial insurer policies have on patients and the providers that care for them. The AHA continues to push back forcefully against MA plan policies that restrict or delay patient access to care, and add cost and burden to the health care system, while also contributing to health care worker burnout. We’ll continue to make the case that these commercial health plan abuses must be addressed to protect patients’ health and ensure that medical professionals — not the insurance industry — are making the key clinical decisions in patient care.”

Related News Articles

Headline
The Centers for Medicare & Medicaid Services Sept. 30 issued a memo, through the Health Plan Management system, finalizing the Medicare Advantage…
Headline
The AHA Sept. 29 sent recommendations to the Department of Health and Human Services and the Centers for Medicare & Medicaid Services to help ensure…
Headline
The Centers for Medicare & Medicaid Services announced Sept. 26 that average premiums for Medicare Advantage and Part D would decline slightly in 2026.…
Headline
The AHA expressed support Sept. 22 to House and Senate sponsors of the Medicare Advantage Prompt Pay Act (H.R. 5454/S. 2879), legislation that would apply a…
Headline
The Centers for Medicare & Medicaid Services Sept. 18 released a final rule on policy and technical changes to Medicare Advantage, the Medicare…
Headline
The AHA Sept. 15 expressed support for the Ensuring Access to Essential Providers Act, legislation that would require Medicare Advantage plans to cover…