Federal report finds Medicare Advantage Plans deny medically necessary care

April 29, 2022

The U.S. Department of Health and Human Services Office of Inspector General (OIG) yesterday published a new report finding that Medicare Advantage (MA) plans have exhibited a pattern of denying prior authorization and payment requests that met Medicare coverage and billing rules. The report describes the avoidable delays, extra steps, and administrative burden caused by these practices and affirms the findings of CMS’ annual audits of MA plans, which have previously highlighted “widespread and persistent problems related to inappropriate denials of services and payment.”

Specifically, the OIG report identifies that inappropriate denials of prior authorization and payment requests have resulted from MA plans:

  • using MA clinical criteria that are inconsistent with and often more restrictive than the coverage rules for fee-for-service (FFS) Medicare;
  • requesting unnecessary documentation; and
  • making manual review errors and system errors.

The report also reflects the negative impact of MA plan practices on patients, providing a detailed appendix with dozens of patient case examples that describe denials for requests that adhered to Medicare coverage rules — often resulting in harm and increasing costs.

Finally, the report concludes with a series of recommendations designed to increase the accountability of MA plans and “ensure that MA beneficiaries have timely access to all necessary health care services and that providers are paid appropriately.” It is noted that CMS concurred with the recommendations, which include:

  • Issuing new guidance on the appropriate use of MA clinical criteria in medical necessity reviews;
  • Updating CMS audit protocols to address MA use of more restrictive clinical criteria and/or examining particular service types in audits where these practices are more common; and

Directing MA plans to take steps to identify and address vulnerabilities that lead to manual review errors and system errors.

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