Thirteen percent of denied prior authorization requests made by Medicare Advantage organizations met Medicare coverage rules, according to a review conducted by the HHS Office of Inspector General released in April.
The office used a sample of 250 prior authorization denials and 250 payment denials issued by 15 of the largest Medicare Advantage organizations from June 1-7, 2019.
Five things to know:
1. The office identified two common reasons for the prior authorization denials: Providers used clinical criteria not outlined in Medicare coverage rules, and some prior authorization requests did not have enough documentation to gain approval.
2. Eighteen percent of denied payment requests met Medicare coverage rules and billing rules.
3. Most payment denials were due to errors made during the claims review process.
4. Imaging services, stays in post-acute facilities and injections were three commonly denied services.
5. The office recommends that CMS issue new guidance on the use of clinical criteria and update its audit protocols.