OIG report highlights beneficiary protections as Medicare Advantage program grows

The Centers for Medicare & Medicaid Services (CMS) has taken a strong position on the future of Medicare Advantage (MA) as a fiscally responsible, quality-oriented reimbursement model by recently finalizing an 8.5% annual growth rate for the program in its calendar year (CY) 2023 Rate Announcement. Along with this investment in the program, CMS released the CY 2023 Medicare Advantage and Part D final rule, which, in part, aims to solidify beneficiary protections for those enrolled in MA plans. However, a recent report has raised concerns over denial of medically necessary care by some plans and recommends additional scrutiny.

OIG report raises concerns about beneficiary access to care

The final rule was published shortly before a report by the Office of the Inspector General (OIG), which found that some Medicare Advantage Organization (MAO) denials of prior authorization requests may have been inappropriate. Of the 430 reviewed prior authorization and payment denials issued by 15 large MAOs, the report noted:

• 13% of prior authorization requests MAOs denied met Medicare coverage rules
• 18% of claims payment requests MAOs denied met Medicare coverage and MAO billing rules
• Some denials were reversed upon appeal, or the MAO discovered its own error
• Imaging services, stays in post-acute facilities, and injections were most prominent among denials that met Medicare coverage rules

CMS concurred with OIG's findings in the report and indicated that it plans to issue clarifying guidance regarding the appropriate use of clinical criteria in medical necessity reviews. The American Medical Association also weighed in, calling for the passage of The Improving Seniors’ Timely Access to Care Act to “rein in excessive and unnecessary prior authorization requirements and improve care delivery for America’s seniors.”

Balancing cost containment with care access by deploying synergistic data analytics

MAOs are reimbursed in a manner that encourages cost containment and delivery of high-quality care. If traditional fee-for-service based regulations are applied to an MAO’s operations, the effectiveness of managed care strategies that have driven success in Medicare risk adjustment may be impacted. Balance is needed to ensure MA beneficiaries receive timely, medically necessary, and appropriate access to healthcare.

As CMS considers additional guidance and regulations, MAOs will need to implement innovative strategies and solutions while adhering to existing regulatory guidance. Purposeful, informed decision-making will drive successful financial and clinical results. To improve MA beneficiaries’ health outcomes and meet the health plan's business objectives, seek a data analytics partner that allows your organization to:

• Leverage a population health solution that offers risk scoring, stratification, and incorporates social determinants of health data, as it becomes more available, while prioritizing interventions for cohorts of members with actionable health needs.
• Integrate HEDIS^® measures and other clinical guidelines into the population health solution to create internal efficiencies to advance the pace at which members care gaps are closed.

• Communicate clinical documentation requirements clearly between plan and community physicians to drive accuracy in each member’s risk score.
• Develop an understanding of providers' risk readiness with an analytics solution that highlights those providing high vs. low-value care, which will impact a plan's Star Ratings.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).