OIG Findings Show Questionable Behavior by Medicare Advantage Organizations

May 4, 2022 by Alexa Hornbeck
OIG Findings Show Questionable Behavior by Medicare Advantage Organizations

The U.S Department of Health and Human Services Office of Inspector General released a report last Friday that shows Medicare Advantage organizations either had delayed or denied care to Medicare beneficiaries even though they met coverage rules.  

The OIG conducted the nearly 60-page report by stratifying a random sample of 250 denials of prior authorization requests and 250 payment details issued by 15 of the largest Medicare Advantage organizations during June 1-7, 2019. 

According to the report, MOAs denied prior authorization and payment requests that met Medicare coverage rules by using clinical criteria that was not contained in Medicare coverage rules, requesting unnecessary documentation from beneficiaries, and making manual review errors and system errors.

The OIG issued recommendations for the Centers for Medicare and Medicaid Services to issue new guidance on the appropriate use of Medicare Advantage organization clinical criteria in medical necessity reviews and updating audit protocols to examine areas identified in the report. 

It also recommends CMS to direct Medicare Advantage organizations to take steps to identify and address any vulnerabilities that could lead to review and system errors. 

Alexa can be reached at [email protected]

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