In an article entitled How Medicare Advantage plans wrongly deny prior auth requests, the American Medical Association highlights findings from a recent Department of Health and Human Services Office of the Inspector General Report. The OIG Report found that 13% of the sampled prior authorization requests denied by Medicare Advantage plans met Medicare’s clinical coverage rules and that 18% of the sampled denied claims met both Medicare coverage rules and Medicare Advantage plan billing rules.
The AMA has long advocated for measures to reduce the burdens of prior authorization on physicians, which frequently serve only to delay or deny medically necessary care. In response to the OIG Report, AMA President-Elect Jack Resneck, Jr., MD told the New York Times that “Medicare Advantage plans’ denials have become commonplace, and that prior authorization has ‘spread way beyond its original purpose.’”
In a statement, current AMA President Gerald E. Harmon, MD stated that AMA surveys of physicians “have consistently found that excessive authorization controls required by health insurers are persistently responsible for serious harm when necessary medical care is delayed, denied, or disrupted.”
Whatley Kallas represents healthcare providers in challenging improper payer denials.