In a very strongly worded letter, the American Hospital Association has urged the Department of Justice to establish a task force to conduct False Claims Act investigations into commercial Medicare Advantage insurers that routinely deny patient access to services and deny payments to health care providers.
By law, Medicare Advantage plans are prohibited from imposing additional clinical criteria more restrictive than original Medicare. However, a recent Department of Health and Human Services Inspector General Report entitled “Some Medicare Advantage Organization Denials of Prior Authorization Request Raise Concerns about Beneficiary Access to Medically Necessary Care” showed that Medicare Advantage plans have been violating this requirement. Specifically, based on an examination of claims from the largest Medicare Advantage plans from one week, the OIG Report found that 13% of the prior authorization denials and 18% of the denied payment requests met Medicare coverage rules and should have been authorized.
Following up on the OIG Report, AHA letter stated:
It is time for the Department of Justice to exercise its False Claims Act authority to both punish those MAOs [Medicare Advantage Organizations] that have denied Medicare beneficiaries and their providers their rightful coverage and to deter future misdeeds. This problem has grown so large – and has lasted for so long – that only the prospect of civil and criminal penalties can adequately prevent the widespread fraud certain MAOs are perpetrating against sick and elder patients across the country, as well as against the public fisc every time commercial insurers take $1,000 per beneficiary while denying medically necessary services.
(emphasis in the original)
The letter gave specific examples of patients whose care had been denied cited in the OIG Report and pointed out that the fraud uncovered in the OIG’s investigation fit squarely within the Department of Justice’s expressed priorities. Therefore, the AHA urged the Department of Justice “to create a ‘Medicare Advantage Fraud Task Force’ to investigate those MAOs that are failing to live up to the commitments they make to the federal government and the Medicare beneficiaries they have been entrusted to serve.” (emphasis in the original)
Whatley Kallas, LLP’s experience representing provider clients challenging Medicare Advantage and commercial insurers’ payments of claims has likewise uncovered myriad examples of inappropriately denied and underpaid claims.