June 30, 2022
The Office of the Inspector General (OIG) recently released a report that indicated Medicare Advantage Organizations (MAO) denied prior authorization requests for medically necessary services that would typically be allowed by the traditional Medicare program. MAOs are not allowed to implement more restrictive clinical criteria than original Medicare requirements. However, the OIG found that prior authorization and payment denials violated Medicare clinical guidelines.
As a result of the OIG report, the American Hospital Association (AHA) has asked that health plans who “routinely deny access to care and services” be further investigated.