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OIG Questions Medicare Advantage Denials

Healthcare providers have long struggled under the administrative burden of prior authorization requirements imposed by Medicare Advantage (MA, also known as Medicare Part C) plans, as well as arbitrary prior authorization denials, utilization controls, and coverage denials by MA plans. The Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently took note of some of the issues providers are having with MA plans and may present a new avenue for providers dealing with these issues.

A recent OIG review of MA prior authorization requirements revealed that an estimated 13% percent of prior authorization requests which were denied by MA plans in fact met Medicare coverage rules and likely would have been approved under fee-for-service Medicare. OIG also determined that about 18% of MA claim denials in fact met Medicare coverage and Medicare Advantage billing rules. Further, OIG found that, on appeal, MA plans only reverse about 3% of prior authorization denials and about 6% of claim denials within three months. According to OIG’s analysis, advanced imaging services such as MRIs and CT scans, post-acute care following hospital stays, and pain relief injections were the most commonly affected services.

MA plans are generally required to follow Medicare coverage rules and their standards can’t be more restrictive than Medicare’s traditional national or local coverage determinations. However, MA plans often deny claims for arbitrary reasons, impose coverage criteria that do not exist under Medicare, or attempt to force provider to alter their utilization of medically necessary services to meet the MA plan’s arbitrary expectations. Moreover, the appeals processes offered by MA plans are often poorly defined and inconsistently administered.

The Centers for Medicare and Medicaid Services (CMS) largely agreed with OIG’s report and recommendation, but offered little in the way of tangible solutions for providers. CMS indicated it would issue new guidance to MA plans in the future and directed MA plans to review their internal processes. Intriguingly, however, OIG recently invited providers who identify patterns of inappropriate denials or utilization controls that impede access to necessary care to share their data with CMS. While not appropriate in every MA appeal, some providers may find more success in an MA appeal where CMS is made aware of the MA plan’s conduct. It is unclear whether OIG will move to address similar arbitrary denials and appeal decisions by the contractors who administer fee-for-service Medicare.

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