On April 28, 2022, the OIG issued the attached 61-page report that found Medicare Advantage Organizations denied and delayed services to beneficiaries that were covered under Medicare rules.
Plans also denied payment to providers for services that met coverage and billing rules.
The OIG used a random sample of 250 prior authorization denials and 250 payment denials during June 1-7, 2019.
- “Among the prior authorization requests that MAOs denied, 13 percent met Medicare coverage rules—in other words, these services likely would have been approved for these beneficiaries under original Medicare.”
- “Among the payment requests that MAOs denied, 18 percent met Medicare coverage rules and MAO billing rules.”
Recommendations for CMS:
- Issue new guidance on the appropriate use of MAO clinical criteria in medical necessity reviews.
- Update its audit protocols to address the issues identified in this report, such as MAO use of clinical criteria and/or examining service types; and
- Direct MAOs to take steps to identify and address vulnerabilities that can lead to manual review errors and system errors.
CMS concurred with all three recommendations.