The Office of the Inspector General (OIG) has released a report concluding what we clinicians already knew – that the prior authorization (PA) process of some Medicare Advantage Organizations (MAO) delays medically-necessary care that is covered under Medicare rules. Here’s a link to the OIG report.

Clinicians who can’t get necessary care authorized for patients already knew this about MAOs, but it should not be a surprise since a major reason for creating MAOs was to implement prior authorization in order to curb improper and over-utilization of some Medicare services. But I digress. The reason for the OIG investigation was that, while MAOs approve the vast majority of requests for services and payment, annual audits conducted by the Centers for Medicare and Medicaid Services (CMS) have found widespread and persistent problems related to inappropriate denials. To conduct its investigation, the OIG selected a random sample of 250 denials of prior authorization requests and 250 payment denials issued by 15 of the largest MAOs during June 1−7, 2019. Health care coding experts reviewed case files for all cases, and physician reviewers examined medical records for a subset of cases.

The analysis showed that about 13% of the denied services met Medicare coverage rules, meaning these services likely would have been approved for these beneficiaries under original Medicare fee-for-service (FFS). MAOs denied PA and payments that met Medicare coverage rules by using clinical criteria that are not contained in Medicare coverage rules, and by requesting unnecessary documentation (among other techniques). We’d all raise a cheer if we were not so fed up and weary from trying to get necessary services authorized.

The more scary statement in the OIG report was this, “Although our review determined that the requests in these cases did meet Medicare coverage rules, CMS guidance is not sufficiently detailed to determine whether MAOs may deny authorization based on internal MAO clinical criteria that go beyond Medicare coverage rules” (italics mine, CF). In other words, it may be more or less “legal”…?