The HHS Office of the Inspector General’s report found that 13 percent of Medicare Advantage prior authorization request denials would have been approved for beneficiaries under original Medicare coverage rules. The report also found 18 percent denied payment requests met Medicare coverage rules and Medicare Advantage Organization billing rules.
“Seniors should not be denied care for routine treatments and procedures that would otherwise be covered,” Reps. Suzan DelBene, D-Wash., Mike Kelly, R-Pa., Ami Bera, D-Calif., and Larry Bucshon, R-Ind. said in an April 28 news release. “This complicates and delays care and worsens health outcomes for this vulnerable population.”
The four lawmakers introduced a bill in May 2021 aimed at reforming the Medicare Advantage prior authorization process. The bill would require Medicare Advantage Organizations to report to CMS on the extent of their use of prior authorization and rates of approvals or denials, according to a news release from Ms. DelBene office. It would also establish an electronic prior authorization process.
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