Medicare Advantage Regulatory Scrutiny Keeps Pace with Growth: OIG Report Examines Prior Authorization and Payment Denial Errors

Lexology June 13, 2022
Ropes & Gray LLP

Introduction

On April 28, 2022, the United States Department of Health and Human Services’ Office of Inspector General (“OIG”) issued a report finding that 15 of the largest Medicare Advantage Organizations (“MAOs”) in the United States have at times denied or delayed beneficiary access to care and provider payment requests for services that met Medicare coverage and MAO billing rules (the “Report”). The OIG based its findings on a stratified random sample of 250 prior authorization and 250 payment denials selected from June 1–7, 2019, and determined that several factors impacted denials, including the imposition of MAO clinical criteria that are not contained in Medicare coverage rules, MAO requests for supplemental documentation despite sufficient showings of medical necessity, and both...

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