America's Health Insurance Plans is criticizing an April 27 report from the HHS Office of Inspector General that found Medicare Advantage Organizations sometimes delayed or denied enrollees' access to services even though the request met Medicare coverage rules.
"While some outspoken critics raise concerns about the program's performance, a clear look at the data finds that Medicare Advantage is improving affordability and access to high-quality care for the people it serves," the insurance group wrote April 29.
The OIG investigation was conducted by selecting a stratified random sample of 250 denials of prior authorization requests and 250 payment denials issued by 15 of the largest Medicare Advantage Organizations from June 1-7, 2019.
The report found that 13 percent of prior authorization request denials would have been approved for beneficiaries under original Medicare coverage rules. Eighteen percent of denied payment requests met Medicare coverage rules and Medicare Advantage Organization billing rules.
"Denied requests that meet Medicare coverage rules may prevent or delay beneficiaries from receiving medically necessary care and can burden providers," the report stated.
The report concluded that most payment denials were caused by human error during manual claims processing review and system processing errors, and Medicare Advantage Organizations reversed some of the denied requests. Reversals often occurred after a beneficiary or provider appealed or disputed the denial, but organizations sometimes identified their own errors.
AHIP believes Medicare Advantage critics are working to "misconstrue the report's context and use it to mistakenly portray Medicare Advantage as a system where care is frequently denied to patients."
AHIP points out that the OIG found 95 percent of prior authorization requests in 2018 were approved. Of the requests OIG examined in June 2019, 87 percent of denied prior authorization requests raised no concerns. Of the remaining 13 percent of denied prior authorization requests (33 total), seven were reversed within three months.
The main concern about many of the denied cases was not that they were improper, but that more federal guidance was needed on criteria that plans can use to make coverage determinations. None of the denied payments affected patient care, according to AHIP.
"The sample used is extraordinarily small, examining just 247 prior authorization requests during one week in June 2019, and raising concerns with only 33 of them. Drawing far-reaching conclusions based on a very small sample of data and misleading headlines is not a productive way to improve our healthcare system for patients," AHIP said.