Medicare Advantage pre-authorizations are often unnecessarily denied

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A report from the Office of Inspector General (OIG) raises concerns that organizations are prioritizing profits over patient access to care.

According to a report from BIG.

A concern with the Medicare Advantage payment model is the potential incentive for organizations to refuse services in an effort to increase profits, the study states. As more people enroll in Medicare Advantage, the issue of improper prior authorization denials may have a pervasive effect.

“Denied claims that meet Medicare coverage rules can prevent or delay beneficiaries from receiving medically necessary care and can be a burden on providers,” the report said. “While some of the denials we reviewed were ultimately reversed by AAMs, avoidable delays and additional steps create friction in the program and can create administrative burden for recipients, providers and AAMs.”

After reviewing a random sample of 250 prior authorization denials and 250 payment denials issued by 15 of the largest MAOs in 2019, OIG found that 13% of prior authorization denials met Medicare coverage rules and 18 % of chargebacks met Medicare coverage and MAO billing. rules.

For prior authorization denials, the study identified two common causes: MAOs used clinical criteria that are not in Medicare coverage rules, and MAOs reported that some prior authorization requests were not had insufficient documentation to support approval – although the report’s researchers found the records were sufficient for services.

For payment denials, the study concluded that most were due to human error during manual claims processing reviews and system processing errors.

The report also found that AAMs reversed some of the pre-authorizations and denials of payment, often due to calls from patients or providers. In some cases, AAMs identified their own error.

To ensure that MAOs do not unnecessarily deny access to timely care, the OIG recommends that the CMS:

  • Publish new guidelines on the appropriate use of MAO clinical criteria in medical necessity examinations
  • Update its audit protocols to address identified issues
  • Require MAOs to take additional steps to identify and resolve vulnerabilities that may lead to manual review errors and system errors

Best health insurance alliancethe research and advocacy organization supporting Medicare Advantage, responded to the OIG report by reiterating the benefits of the plan and the importance of prior authorization.

“Although this study represents only a small sample of Medicare Advantage beneficiaries and query data shows that less than half of Medicare Advantage beneficiaries have been pre-authorized themselves, Better Medicare Alliance has strongly supported efforts to streamline and simplify the pre-authorization process for patients and providers,” Mary Beth Donahue, president and CEO of the Better Medicare Alliance, said in a statement.. “We look forward to our continued work with policymakers to strengthen Medicare Advantage for today’s seniors and tomorrow’s enrollees.”

the American Hospital AssociationMeanwhile, mentioned The results “confirm—and provide concrete data and examples—of the harm some commercial insurer policies have on patients and the providers who care for them. The AHA continues to forcefully push back against MA Plan policies that restrict or delay patients’ access to care, and increase costs and burden on the health care system, while contributing to the burnout of health care workers.We will continue to argue that these abuses of commercial health care plans must be addressed to protect patient health and ensure that healthcare professionals — not the insurance industry — make key clinical decisions about patient care.”

Jay Asser is associate editor for HealthLeaders.

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