HHS OIG Report On Prior Authorizations Under Medicare Advantage

Lexology May 5, 2022
Sheppard Mullin Richter & Hampton LLP

Last month, the U.S. Department of Health and Human Services Office of Inspector (“OIG”) released a report that studied prior authorization denials and payment denials by Medicare Advantage Organizations (“MAOs”) (the “Report”). While the Report found that the “vast majority” of prior authorizations and payment requests were approved, the Report focused on the finding that MAOs “sometimes” denied prior authorization and payment requests that met Medicare coverage rules claiming that the denials delayed or denied beneficiaries’ access to medically necessary services.

The Report is another example of the OIG fanning the fire of criticism of MAOs by ignoring the overwhelming evidence that MAOs provide access to medically necessary services and also minimized the program requirements and guidance from the Centers...

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