Study issued due to Office of Inspector General concerns that increased profits might be incentive for denial to services.
The Office of Inspector General of the U.S. Department of Health and Human Services (HHS) recently completed a study of Medicare Advantage Organizations (MAO’s) due to a “central concern about the capitated payment model used in Medicare Advantage is the potential incentive for Medicare Advantage Organizations (MAOs) to deny beneficiary access to services and deny payments to providers in an attempt to increase profits.”
The report issued by Christi Grimm, Inspector General of HHS, acknowledged that MAO’s approve most requests for services, however they also issue millions of denials every year.
The Office of Inspector General (OIG), according to findings of the report, “determined that MAOs sometimes delayed or denied Medicare Advantage beneficiaries’ access to services, even though the requests met Medicare coverage rules.”
OIG writes, “MAOs used clinical criteria that are not contained in Medicare coverage rules (e.g., requiring an x-ray before approving more advanced imaging), which led them to deny requests for services that our physician reviewers determined were medically necessary.”
The findings also suggested that ambiguity in some of the Centers for Medicare and Medicaid Services (CMS) guidance could contribute to authorization determinations that result in unnecessary denials.
The report issued several recommend changes, including requesting the CMS to issue new guidance, update audit protocols that monitor MAO’s use of clinical criteria, and for CMS to direct “MAOs to take steps to identify and address vulnerabilities that can lead to manual review errors and system errors” which in turn can result in denials or delay of care that beneficiaries should be provided.
CMS is in agreement with the recommendations of the OIG report.