Medicare Advantage Organization denials of prior authorization requests raise concerns

A report from the HHS Office of the Inspector General released April 27 found Medicare Advantage Organizations sometimes delayed or denied enrollees' access to services even though the request met Medicare coverage 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 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. 

Five things to know: 

1. Thirteen percent of prior authorization request denials would have been approved for beneficiaries under original Medicare coverage rules. 

2. Medicare Advantage Organizations indicated that some prior authorization requests did not have enough documentation to support approval, but reviewers found that existing medical records were sufficient to support the medical necessity of the services. 

3. Eighteen percent of denied payment requests met Medicare coverage rules and Medicare Advantage Organization billing rules.  

4. Most payment denials were caused by human error during manual claims processing review and system processing errors. 

5. Medicare Advantage Organizations reversed some of the denied requests. Often the reversal occurred after a beneficiary or provider appealed or disputed the denial. In some cases, the organizations identified their own errors. 

Read the full report here

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