The American Hospital Association (AHA) is asking CMS to take "swift action" against Medicare Advantage organizations (MAOs) that are inappropriately and illegally restricting access to care.
 
In a penned letter, AHA urges for accountability in response to a report by the Office of the Inspector General (OIG) on MAOs, which found that an estimated 13% of prior authorization denials and 18% of payment denials should have been granted.
 
"Inappropriate and excessive denials for prior authorization and coverage of medically necessary services is a pervasive problem among certain plans in the MA program," AHA writes. "This results in delays in care, wasteful and potentially dangerous utilization of fail-first imaging and therapies, and other direct patient harms. In addition, they add financial burden and strain on the health care system through inappropriate payment denials and increased staffing and technology costs to comply with plan requirements."
 
To address the unnecessary denials, AHA recommends that CMS:
 
Work with Congress to streamline MA plan prior authorization processes: Support the Improving Seniors' Timely Access to Care Act of 2021, which streamlines prior authorization requirements under MA plans by making them "simpler and uniform."
  • Improve data and reporting: Have standardized reporting on metrics related to denials, appeals, and grievances, while auditing plans more often.
  • Conduct more frequent and targeted plan audits: Consider targeting audits to MA plans that have a history of unnecessary denials.
  • Establish provider complaint process: Establish a process for providers to submit complaints for suspected violations of bad actors.
  • Align traditional Medicare and MA medical necessity criteria: Prohibit MA plans from using medical necessity criteria that is more restrictive than traditional Medicare.
  • Enforce penalties for non-compliance: Exercise authority in situations in which MA plans fail to comply with rules to support compliance.
  • Provide clarify on the role of states in MA oversight: Give states clarity on the scope of their authority to hold MA plans accountable.
  • Reduce incentives for plans to skimp on coverage: Prohibit MA plans from claiming diagnoses for risk adjustment purposes if the plan has denied coverage for services provided to treat that diagnosis.
Jay Asser is an associate editor for HealthLeaders.