Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care

From: U.S. Department of Health and Human Services Office of Inspector General Our case file reviews determined that MAOs sometimes delayed or denied Medicare Advantage beneficiaries’ access to services, even though the requests met Medicare coverage rules. MAOs also denied payments to providers for some services that met both Medicare coverage rules and MAO billing rules. Denying requests that meet Medicare coverage rules may prevent or delay beneficiaries from receiving medically necessary care and can burden providers.
Although some of the denials that we reviewed were ultimately reversed by the MAOs, avoidable delays and extra steps create friction in the program and may create an administrative burden for beneficiaries, providers, and MAOs. Examples of health care services involved in denials that met Medicare coverage rules included advanced imaging services (e.g., MRIs) and stays in post-acute facilities (e.g., inpatient rehabilitation facilities).
Prior authorization requests. We found that among the prior
authorization requests that MAOs denied, 13 percent met Medicare
coverage rules—in other words, these services likely would have been
approved for these beneficiaries under original Medicare (also known as
Medicare fee-for-service). We identified two common causes of these
denials. First, MAOs used clinical criteria that are not contained in
Medicare coverage rules (e.g., requiring an x-ray before approving more
advanced imaging), which led them to deny requests for services that our
physician reviewers determined were medically necessary. Although our
review determined that the requests in these cases did meet Medicare
coverage rules, CMS guidance is not sufficiently detailed to determine
whether MAOs may deny authorization based on internal MAO clinical
criteria that go beyond Medicare coverage rules. For the full report read more here.