OIG report raises concerns about Medicare Advantage denials of prior authorization requests

In April the Office of Inspector General (OIG) announced the release of a new report, which found that Medicare Advantage Organizations (MAOs) had delayed or denied beneficiaries’ access to services that meet Medicare coverage requirements under prior authorization requests. The report also found that these plans had rejected payments to providers that met coverage and billing requirements, refusing beneficiaries’ access to medically necessary care.

The OIG report indicates that while MAOs approve a sizeable majority of services and payments, they reject millions of claims for services and payment annually. While some denials have been reversed by the MAO or by provider and beneficiary appeal, CMS annual audits of MAOs underscore vast, pervasive, and ongoing problems concerning incorrect denials of services and payments that meet Medicare coverage and billing requirements for medical necessity.

MAO plan enrollment continues to rise, and MAOs play an increasingly vital role in safeguarding access to medically necessary care for Medicare beneficiaries and appropriate provider payment for Medicare covered services. However, there is an ongoing concern about the for-profit practices of MAOs, and the grounds and circumstances under which MAOs reject prior authorization services and payment requests that meet Medicare coverage and MAO billing requirements, which is detailed in the OIG report.

Members may send questions about this report to the AASM health policy team at coding@aasm.org. Find additional coding and reimbursement resources from the AASM.