Medicare Advantage plans' use of prior authorization is raising some eyebrows at the Office of Inspector General.
A new report (PDF) from the Department of Health and Human Services OIG found that MA organizations at times delay or deny beneficiaries' access to services that meet Medicare coverage requirements. Plans also rejected payments to providers that met coverage and billing requirements, according to the report.
OIG analyzed a stratified, random sample of 250 prior authorization denials and 250 payment denials issued by 15 of the largest MA insurers between June 1 and June 7, 2019. From that sample, the analysts extrapolated likely denial rates that fit within Medicare's requirements.
OIG found that 13% of prior authorization denials fit within Medicare coverage requirements, as did 18% of denied payment requests. Medicare Advantage plans did reverse some denials that did fit within the Medicare coverage guidelines, typically when a patient or provider disputed the denial or the insurer identified its own error.
"Our findings about the circumstances under which MAOs denied requests that met Medicare coverage rules and MAO billing rules provide an opportunity for improvement to ensure that Medicare Advantage beneficiaries have timely access to all necessary health care services, and that providers are paid appropriately," OIG said in the report.
The agency suggested that the Centers for Medicare & Medicaid Services issue new guidance on appropriate clinical criteria, update audit protocols to flag issues and take steps to identify and address vulnerabilities that can lead to errors. CMS concurred with all three recommendations.
The American Medical Association said in a statement that OIG's report "mirrors physician experiences" with Medicare Advantage plans. The group said addressing these hurdles is why it backs the Improving Seniors' Timely Access to Care Act, which would mandate that MA plans streamline and standardize their prior authorization requirements, as well as make those requirements more transparent.
"The proposed federal legislation has gained bipartisan support from more than 300 members in both chambers of Congress," AMA President Gerald Harmon, M.D., said in a statement. "The time is now for federal lawmakers to act to improve and streamline the prior authorization process so that patients are ensured timely access to the evidence-based, quality health care they need.”
The Medicare Advantage program has grown significantly of late and with that growth has come increased scrutiny. In addition to putting prior authorization practices under the microscopes, risk adjustment has gotten a closer look as critics of the program charge MA plans are gaming the system to juice their profits.