Following up on the recent report from the HHS Inspector General raising concerns that Medicare Advantage (MA) plans’ prior authorization practices deny beneficiary access to medically necessary care, FAH wrote to CMS Administrator Brooks-LaSure urging prompt implementation of the OIG’s recommendations and taking further steps to protect beneficiaries and address program abuses.
The letter notes that “OIG’s findings reflect a broader pattern of MAO practices that inappropriately deny, limit, modify or delay the delivery of or access to services and care for MA beneficiaries.” These practices include inadequate provider networks, extended observation stays, retroactively reclassified patient status, improperly downcoded claims, and inappropriate clinical criteria. Among FAH’s recommendations for action, CMS should:
- Apply to MA plans both Medicare’s Two-Midnight Rule and the Inpatient-Only List.
- Issue guidance to ensure MA plans do not disproportionately burden access to particular provider types such as inpatient rehabilitation facilities (IRF) and long-term acute care hospitals. This is especially important as OIG notes plans may have an incentive to deny care over cost concerns, citing inpatient rehabilitation facilities (IRF) as an example.
- Undertake targeted audits focusing on IRF and other service types that have a history of inappropriate denials.
- Curb unfair practices such as MA use of remote third-party contractors improperly motivated by contingency fee audits, acting as bounty hunters to deny and degrade claims.
- Improve transparency and quality incentives for MA Stars Rating programs, such as reporting and assessing performance on a measure examining overturn rates on Level 1 Appeals.
Click here to review the full letter.