‘Staggering’: Watchdog Finds Medicare Advantage Plans Deny Necessary Care

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      Government investigators found that 13% of the 12,273 prior authorization denials met Medicare coverage rules. “In other words,” the report explains, “these services likely would have been approved for these beneficiaries under original Medicare (also known as Medicare fee-for-service).”

      “These denials can delay or prevent beneficiary access to medically necessary care; lead beneficiaries to pay out of pocket for services that are covered by Medicare; or create an administrative burden for beneficiaries or their providers who choose to appeal the denial,” the report continues. “These denials may be particularly harmful for beneficiaries who cannot afford to pay for services directly and for critically ill beneficiaries who may suffer negative health consequences from delayed or denied care.”

      The report points out that “for 3% of prior authorization denials, MAOs initially denied requests that met Medicare coverage rules, and later reversed these denials within three months and approved the requests.” The investigators also found that 18% of the 160,378 reviewed payment denials “met Medicare coverage rules and MAO billing rules and should have been approved by the MAOs.”

      “For an annual context, if these MAOs denied the same number of payment requests (28,949) in each of the other 51 weeks of 2019,” the report states, “they would have denied 1.5 million payment requests that met Medicare coverage rules and MAO billing rules that year. “

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