Staff Contact: Andrew Wheeler
HHS’ OIG released a study about Medicare Advantage prior authorization denials raising concerns about beneficiary access to care. The OIG found that MA plans denied requests to send patients recovering from hospital services to a SNF or IRF when physicians determined that those places were more appropriate than the patient home, found that MA plans denied payments that met both Medicare and MA coverage rules and found avoidable delays in granting authorizations. Although the MA plans asserted that some prior authorization requests did not have sufficient supporting documentation, the OIG “reviewers found that the existing beneficiary medical records were sufficient to support the medical necessity of the services.” The OIG urges Medicare officials to strengthen oversight of the MA plans and calls for increased enforcement against plans with a pattern of inappropriate denials. Several recommendations also were included in previous OIG reports about MA prior authorization practices.
