Just as health care providers suspected, Medicare Advantage Organizations (MAO) inappropriately deny requests for pre-authorization of services and payment! In fact, as per the Office of Inspector General’s (OIG) report released this month MAO’s overturn their own denials about 75% of the time, when appealed by providers and/or beneficiaries. Sadly, most providers and beneficiaries do not appeal.
The OIG analyzed data from CMS, the Office of Medicare Hearings and Appeals, and the Departmental Appeals Board and reviewed it against CMS’ own annual performance data for each MAO for the years 2014-2016. The findings are not unfamiliar or surprising to health care providers. Read the full report here: Medicare Advantage Appeal Outcomes and Audit Findings Raise Concerns About Service and Payment Denials.