Medicare Advantage Denials - April 2022 HHS INspector General report

The Office of Inspector General within Health and Human Services (HHS) recently released a report outlining an audit of service denials from Medicare Advantage Organizations.  The full report can be found using this link.

Some of the key highlights from the report can be found below (and summarized in the video above).

• 13% of Pre-Authorization Denials met Medicare coverage rules and thus, should not have been denied
• 18% of Payment Denials met Medicare coverage rules and thus, should not have been denied

The estimated annual impact of these issues on Medicare Beneficiaries was extrapolated to the following:

• ~85,000 Beneficiary pre-authorization requests denied that should not have denied
• ~1.5m Payment requests denied that met Medicare coverage and billing rules

The Top 3 impacted areas for these denials were:

• Advanced Imaging (e.g. MRIs, Scans, etc.)
• Post-Acute Care
• Injections

There were three recommendations that the Inspector General is requesting of CMS (Center for Medicare and Medicaid Services).

1. Issue new guidance on appropriate use of Medicare Advantage Organizations clinical criteria in medical necessity reviews
2. Update audit protocols to address the new criteria in #1
   
3. Direct Medicare Advantage Organizations to take steps to identify and address vulnerabilities that can lead to these errors.
   

CMS has acknowledged and agreed to implement these recommendations.

Hopefully, this improves the overall experience for Medicare Advantage Plans going forward.