Washington E-Newsletter

Federal Watchdog Agency Raises Concerns about Prior Authorization in Medicare

On April 28, the U.S. Department of Health and Human Services Office of Inspector (OIG) General released a report criticizing prior authorization in the Medicare Advantage program. According to the report titled “Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care,” an estimated 13% of denied prior authorization requests reviewed met Medicare coverage rules and likely would have been approved under fee-for-service Medicare. Moreover, the OIG found that about 18% of denied payment requests met Medicare coverage and Medicare Advantage billing rules. The OIG recommends, among other things, that the Centers for Medicare & Medicaid Services (CMS) update its guidance on the clinical criteria for medical necessity reviews and revise audit protocols for Medicare Advantage plans.

Following the report, the sponsors of H.R. 3173, the Improving Seniors’ Timely Access to Care Act, which would streamline prior authorization in the Medicare Advantage Program, issued a press release stating:

“Today’s HHS Inspector General report underscores the urgent need for reforms in the current prior authorization system. Seniors should not be denied care for routine treatments and procedures that would otherwise be covered. This complicates and delays care and worsens health outcomes for this vulnerable population.

It is well past time to bring prior authorization into the 21st century so seniors can get the care they deserve by passing the Improving Seniors’ Timely Access to Care Act. The reforms in this legislation have widespread bipartisan support and the backing of hundreds of leading national health care organizations. The House must move on this bill quickly.”

With nearly 300 co-sponsors, this legislation is poised to move forward in the House of Representatives and would be a significant step in reforming prior authorization in Medicare.

Click here for the OIG report and here for a video related to the report.