MA plans deny care traditional Medicare would cover, investigation finds

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

The Centers for Medicare and Medicaid Services agreed with policy recommendations laid out in a federal report published Thursday showing how prior authorization has prevented enrollees from accessing necessary care.

An estimated 13% percent of denied prior authorization requests reviewed met Medicare coverage rules and likely would have been approved under fee-for-service Medicare, according to the Health and Humans Services Department’s inspector general. The watchdog further determined that about 18% of payment requests insurance companies denied met Medicare coverage and Medicare Advantage billing rules. Insurers reversed their prior authorization denials in about 3% of cases and their payment denials in 6% of cases within three months, the Office of Inspector General found.

The OIG examined data from the 15 largest Medicare Advantage companies—including UnitedHealth Group, Humana, CVS Health, Kaiser Permanente and Anthem—over a one-week period in June 2019.

Advanced imaging services—such as MRIs and CT scans—post-acute care following hospital stays and injections used mainly for pain relief were the most commonly denied services, according to the inspector general.

In a statement, the insurance trade group AHIP emphasized that the report shows most Medicare Advantage prior authorization requests are approved and cautioned against making broad conclusions due to the report’s limited sample.

The OIG’s findings echo longstanding complaints from providers and patients that Medicare Advantage carriers apply prior authorization and medical necessity reviews in a way that is detrimental to patient, said Terrence Cunningham, director of administrative simplification policy at the American Hospital Association.

“Our hope would be that the analysis really pushes regulators and legislators to take steps to ensure that Medicare Advantage beneficiaries are entitled to appropriate and medically necessary care and that Medicare Advantage organization policies do not get in the way of that,” Cunningham said.