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Medicare Benefit Prior Authorizations are Usually Unnecessarily Denied

A report by the Workplace of Inspector Normal (OIG) raises issues about organizations prioritizing income over affected person entry to…

By Staff , in Medicare , at May 8, 2022

A report by the Workplace of Inspector Normal (OIG) raises issues about organizations prioritizing income over affected person entry to care.

Medicare Benefit organizations (MAOs) typically delay or deny providers for medically vital care, even when prior authorization requests meet protection guidelines, based on a report by the OIG.

A priority with the Medicare Benefit cost mannequin is the potential incentive for organizations to disclaim providers in an try to extend income, the research states. As an increasing number of folks enroll in Medicare Benefit, the problem of inappropriate prior authorization denials can have a widespread impact.

“Denied requests that meet Medicare protection guidelines might stop or delay beneficiaries from receiving medically vital care and may burden suppliers,” the report stated. “Though among the denials that we reviewed have been in the end reversed by the MAOs, avoidable delays and additional steps create friction in this system and will create an administrative burden for beneficiaries, suppliers, and MAOs.”

After reviewing a random pattern of 250 prior authorization denials and 250 cost denials issued by 15 of the biggest MAOs in 2019, the OIG discovered that 13% of prior authorization denials met Medicare protection guidelines and 18% of cost denials met Medicare protection and MAO billing guidelines.

For the prior authorization denials, the research recognized two frequent causes: MAOs used medical standards that aren’t contained in Medicare protection guidelines, and MAOs indicated that some prior authorization requests didn’t have sufficient documentation to help approval—although researchers of the report discovered medical data have been ample for providers.

For the cost denials, the research concluded that the majority have been brought on by human error throughout guide claims processing critiques and system processing errors.

The report additionally discovered that MAOs reversed among the prior authorization and cost denials, typically due to affected person or supplier appeals. In some instances, MAOs recognized their very own error.

To make sure that MAOs aren’t unnecessarily denying well timed entry to care, the OIG recommends that CMS:

  • Problem new steering on the suitable use of MAO medical standards in medical necessity critiques
  • Replace its audit protocols to handle the recognized points
  • Direct MAOs to take extra steps to determine and deal with vulnerabilities that may result in guide evaluation errors and system errors

Higher Medicare Alliance, the analysis and advocacy group supporting Medicare Benefit, responded to the OIG report by reiterating the advantages of the plan and the significance of prior authorization.

“Whereas this research represents solely a slender pattern of Medicare Benefit beneficiaries and polling information reveals that lower than half of Medicare Benefit beneficiaries have ever skilled a previous authorization themselves, Higher Medicare Alliance has strongly supported efforts to streamline and simplify the prior authorization course of for sufferers and suppliers,” Mary Beth Donahue, president and CEO of Higher Medicare Alliance, stated in a press release. “We stay up for our continued work with policymakers to strengthen Medicare Benefit for at present’s seniors and tomorrow’s enrollees.”

The American Hospital Affiliation, in the meantime, stated the findings “affirm—and supply information and real-life examples—of the hurt that sure business insurer insurance policies have on sufferers and the suppliers that take care of them. The AHA continues to push again forcefully in opposition to MA plan insurance policies that prohibit or delay affected person entry to care, and add price and burden to the well being care system, whereas additionally contributing to well being care employee burnout. We’ll proceed to make the case that these business well being plan abuses have to be addressed to guard sufferers’ well being and be sure that medical professionals—not the insurance coverage business—are making the important thing medical choices in affected person care.”

Jay Asser is an affiliate editor for HealthLeaders.

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