HHS Office of Inspector General Drives Major Reforms to Medicare Advantage Prior Authorization Processes. Here's what you should know: 👉
A recent HHS Office of Inspector General (OIG) brief (https://lnkd.in/emgGReZ4) has catalyzed significant reforms around prior authorization processes in the Medicare Advantage (MA) program. The brief highlighted alarming cases where MA enrollees faced delays or denials of medically necessary care due to overly restrictive prior auth policies.
In one case, a 76-year-old man with post-polio syndrome was denied a $112 walker - despite being at high risk of falls - because he had received a cane within the past 5 years. Another enrollee's physician-ordered MRI for continuing pain was denied for lack of a preceding X-ray.
The OIG found that an estimated 13% of the over 1 million prior authorization denials issued by MA plans in 2019 were for services meeting medical necessity criteria. This brief drew national attention to the issue.
CMS and Industry Respond with Major Reforms:
In response, the Centers for Medicare and Medicaid Services (CMS) issued new rules in January and April 2024 aimed at decreasing delays in care and preventing inappropriate denials through clearer prior authorization guidelines aligned with Medicare coverage policies.
Major insurers like UnitedHealth, Cigna, and Aetna have also reduced the number of services requiring prior approval by up to 20% to cut administrative burden and increase patient access.
Congressional hearings in 2022 and 2023 further highlighted the risks to MA enrollees from prior auth practices. The House passed legislation to create an electronic prior authorization process to reduce delays.
Impacts for Health Plans and Systems:
These reforms from CMS, insurers, and Congress represent a significant operational shift for MA plans. Health system leaders should closely review the new prior authorization rules and requirements to ensure compliance and prevent any more cases of delayed or denied medically necessary care.
While reducing administrative burdens, health plans must also enhance processes for making timely, well-substantiated coverage determinations fully aligned with Medicare policies. Investing in streamlined prior auth technology and optimizing clinical review workflows will be critical.
The OIG brief served as a wake-up call on the patient impacts of overly restrictive prior authorization. By driving major reforms, it has ushered in a new era of increased scrutiny and mandate for ensuring MA enrollees have proper access to care.
