MA Plans Deny Medical Care Covered by Traditional Medicare, Investigation Shows

Medicare Advantage insurers may soon see more oversight of prior authorization practices.

The Centers for Medicare and Medicaid Services agreed with the policy recommendations outlined in a federal report released Thursday that shows how prior authorization prevented members from accessing the care they need.

The Inspector General of the Department of Health and Human Services estimates that approximately 13% of denied prior authorization requests met Medicare coverage rules and would likely have been approved under Medicare fee-for-service. In addition, the watchdog determined that about 18% of payment requests denied by insurance companies were in line with Medicare coverage rules and Medicare Advantage billing rules. According to the Office of the Inspector General, insurers reversed their pre-clearance denials about 3% of the time and 6% of the time they waived payment denials within three months.

OIG reviewed data from the top 15 Medicare Advantage companies, including UnitedHealth Group, Humana, CVS Health, Kaiser Permanente and Anthem, over a weekly period in June 2019.

The most frequently denied services most often denied are advanced imaging services such as MRI and CT scans, post-surgical care after a hospital stay, and injections used primarily for pain relief, according to the inspector general.

A statement from insurance trade group AHIP highlights that the report shows that the majority of requests for Medicare Advantage Prior Authorization are being approved and cautions against drawing broad conclusions due to the report’s limited sample.

The OIG’s findings echo longstanding complaints from health care providers and patients that Medicare Advantage insurers are applying pre-clearance and medical necessity screening in a way that is detrimental to the patient, said Terrence Cunningham, director of administrative simplification policy at the American Hospital Association.

“We hope that the review will indeed push regulators and legislatures to take action to ensure that Medicare Advantage recipients are eligible for appropriate and medically necessary care and that the policies of the Medicare Advantage Organization do not interfere with this,” Cunningham said.