A 2022 report from the Office of Inspector General examines the issue of prior authorization denials in Medicare Advantage plans. Here are the key findings:

• High Denial Rates: The report found that Medicare Advantage Organizations (MAOs) denied 13% of prior authorization requests, even though the services met Medicare coverage rules.
• Impact on Beneficiaries: These denials can delay or prevent beneficiaries from receiving medically necessary care, potentially leading to adverse health outcomes.
• Inappropriate Denials: Some denials were due to MAOs applying clinical criteria that were not consistent with Medicare coverage rules.
• Recommendations: The OIG recommends that the Centers for Medicare & Medicaid Services enhance oversight of MAOs to ensure that prior authorization requests are appropriately reviewed and that beneficiaries receive timely access to necessary care.

The report highlights the need for improved oversight and transparency to protect beneficiaries’ access to care.