Some Medicare Advantage Organization denials of prior authorization requests raise concerns about beneficiary access to medically necessary care

Some Medicare Advantage Organization denials of prior authorization requests raise concerns about beneficiary access to medically necessary care

Collection:
Health Policy and Services Research
Series Title(s):
Report in brief (United States. Department of Health and Human Services. Office of Inspector General)
Contributor(s):
United States. Department of Health and Human Services. Office of Inspector General. Office of Evaluation and Inspections, issuing body.
Publication:
Washington, DC : U.S. Department of Health and Human Services, Office of Inspector General, April 2022
Language(s):
English
Format:
Text
Subject(s):
Government Regulation
Insurance, Health, Reimbursement -- economics
Medicare Part C -- economics
Medicare Part C -- organization & administration
Prior Authorization -- economics
Time-to-Treatment
United States
United States. Department of Health and Human Services
Genre(s):
Technical Report
Abstract:
Why OIG did this review. A central concern about the capitated payment model used in Medicare Advantage is the potential incentive for Medicare Advantage Organizations (MAOs) to deny beneficiary access to services and deny payments to providers in an attempt to increase profits. Although MAOs approve the vast majority of requests for services and payment, they issue millions of denials each year, and CMS’s annual audits of MAOs have highlighted widespread and persistent problems related to inappropriate denials of services and payment. As enrollment in Medicare Advantage continues to grow, MAOs play an increasingly critical role in ensuring that Medicare beneficiaries have access to medically necessary covered services and that providers are reimbursed appropriately. How OIG did this review. We selected a stratified random sample of 250 denials of prior authorization requests and 250 payment denials issued by 15 of the largest MAOs during June 1−7, 2019. Health care coding experts reviewed case files for all cases, and physician reviewers examined medical records for a subset of cases. From these results, we estimated the rates at which MAOs denied prior authorization and payment requests that met Medicare coverage rules and MAO billing rules. We also examined the reasons for these denials and the types of services associated with these denials in our sample.
Copyright:
The National Library of Medicine believes this item to be in the public domain. (More information)
Extent:
1 online resource (1 PDF file (57 pages))
Illustrations:
Illustrations
NLM Unique ID:
9918419272706676 (See catalog record)
Permanent Link:
http://resource.nlm.nih.gov/9918419272706676