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Medicare Advantage Plans Need to be Held Accountable AHA Says

Analysis  |  By Amanda Norris  
   July 13, 2022

The American Hospital Association (AHA) urged Congress to streamline Medicare Advantage plans' prior authorization requirements in lengthy letter.

The AHA submitted a letter to the House Energy and Commerce Oversight and Investigations Subcommittee calling for greater congressional oversight to protect access to care for Medicare Advantage (MA) beneficiaries.

The letter urged Congress to support legislation for the following:

  • Streamline MA plans' prior authorization requirements
  • Prohibit MA plans from using more restrictive medical necessity and coverage criteria than traditional Medicare
  • Establish a provider complaint process and enforce penalties for plans that fail to comply with federal rules
  • Clarify states' role in MA plan oversight

"Inappropriate and excessive denials for prior authorization and coverage of medically necessary services is a pervasive problem among certain plans in the MA program. This results in delays in care, wasteful and potentially dangerous utilization of fail-first imaging and therapies, and other direct patient harms," the AHA said.

"In addition, these practices add financial burden and strain on the health care system through inappropriate payment denials and increased staffing and technology costs to comply with plan requirements. They are also a major burden to the health care workforce and contribute to worker burnout."

To this point, the AHA refers to an advisory issued last month by Surgeon General Vivek Murthy, that notes that burdensome documentation requirements, including the volume of and requirements for prior authorization, are drivers of healthcare worker burnout.

In the letter, the AHA also urges Congress to require MA plans to publicly report on standard performance metrics related to coverage denials, appeals, and grievances and for CMS to conduct more audits for plans with a history of inappropriate denials.

This latest letter from the AHA comes on the heels of last month's request for CMS to take "swift action" to hold MA plans accountable for inappropriately and illegally restricting beneficiary access to medically necessary care.

Here, the AHA cited an OIG report that found that MA organizations often delay or deny services for medically necessary care, even when prior authorization requests meet coverage rules.

A concern with the MA payment model is the potential incentive for organizations to deny services in an attempt to increase profits, the study said. As more and more people enroll in MA, the issue of inappropriate prior authorization denials can have a widespread effect.

"Denied requests that meet Medicare coverage rules may prevent or delay beneficiaries from receiving medically necessary care and can burden providers," the report said. "Although some of the denials that we reviewed were ultimately reversed by the MA organizations, avoidable delays and extra steps create friction in the program and may create an administrative burden for beneficiaries, providers, and MA organizations."


Amanda Norris is the Director of Content for HealthLeaders.

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