The OIG previously found that 13% of MA prior authorization denials were for services that should have been covered under Medicare rules, often citing plan-specific clinical criteria that exceed Medicare’s own standards.
SNFs should build payer-specific documentation workflows that anticipate the clinical criteria and supporting evidence each MAO requires, and should track appeal outcomes by plan to identify denial patterns — the OIG found that plans frequently apply non-Medicare guidelines and request unnecessary documentation, both of which are grounds for appeal.
Examining Prior Authorization in Health Insurance
Long used as a tool to control spending and to promote cost-effective care, prior authorization in health insurance is in the spotlight as advocates and policymakers call for closer scrutiny about its use across all forms of health coverage.
A recent report from the U.S. Department of Health and Human Services’ (HHS) Office of the Inspector General (OIG) found 13% of prior authorization denials by Medicare Advantage plans were for benefits that should otherwise have been covered under Medicare. The OIG cited use of clinical guidelines not contained in Medicare coverage rules as one reason for the improper denials, as well as managed care plans requesting additional unnecessary documentation. The OIG recommended and HHS agreed that the Centers for Medicare and Medicaid Services (CMS) should take a closer look at the appropriateness of clinical criteria used by Medicare Advantage plans in making coverage determinations.
— KFF, 20 May 2022
Pestaina, Kaye, and Karen Pollitz. “Examining Prior Authorization in Health Insurance.” KFF, 20 May 2022. https://www.kff.org/mental-health/examining-prior-authorization-in-health-insurance/.
Why So Slow? Legislators Take on Insurers’ Delays in Approving Prescribed Treatments
Health plans say that prior authorization requirements help them protect patients’ safety and improve the quality of care, in addition to rooting out waste and error. Doctors disagree. They say that the process too often leads to delays in patient care and that those delays can sometimes cause consumers to abandon treatment.
The complaints aren’t confined to regular commercial coverage. A report released in April by the U.S. Department of Health and Human Services’ inspector general examined a random sample of 250 prior authorization denials at 15 large Medicare Advantage plans in June 2019. It found that 13% of prior authorization denials by Medicare Advantage plans were for services that met Medicare coverage rules.
— KFF Health News, 17 May 2022
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