The Department of Health and Human Services’ top watchdog arm has raised concerns over some Medicare Advantage plans that have denied certain services requested by patients, including those trying to get skilled nursing care.
MA plans issue millions of denials each year and the HHS Office of the Inspector General (OIG) found widespread and persistent problems related to inappropriate denials of services and payments to providers, a report released this week from the government agency showed.
The three most prominent service types most frequently denied were advanced imaging services (including MRIs and CT scans); post-acute care in skilled nursing facilities and inpatient rehabilitation facilities (i.e., care after hospital stays); and injections.
With enrollment in Medicare Advantage exploding across the health care continuum – with Trella Health researchers predicting MA enrollment to eclipse 50% of eligible Medicare beneficiaries in 2025 – the OIG recommends that the Centers for Medicare & Medicaid Services (CMS) issue new guidance for these organizations.
Its recommendations included new guidance on MA organization clinical criteria in medical necessity reviews, updates to its audit protocols to address particular service types and directing the organizations to take steps to identify and address vulnerabilities that can lead to manual review and system errors.
The OIG randomly sampled 250 denials of prior authorization requests and 250 payment denials issued by 15 of the largest organizations from June 1 to June 7, 2019, and had health care coding experts and physicians review the case files and medical records.
The report found that among the prior authorization requests that MA organizations denied, 13% met Medicare coverage rules and likely would have been approved for these beneficiaries under traditional Medicare.
“Denying requests that meet Medicare coverage rules may prevent or delay beneficiaries from receiving medically necessary care and can burden providers,” the OIG said in its report. “Although some of the denials that we reviewed were ultimately reversed by the MAOs, avoidable delays and extra steps create friction in the program and may create an administrative burden for beneficiaries, providers, and MAOs.”
In denied requests for transfers to post-acute care facilities that met Medicare coverage rules, MA plans claimed that beneficiaries’ needs could be met at a lower, less costly level of care.
The MA plans often claimed that the patients did not need intensive therapy or skilled care, and that their needs could be met at a lower level of care, such as home health services at the patient’s residence.
However, several reviews by physician panels determined in these cases where the patients met the clinical criteria for admission to the relevant facilities, they would have benefited from the higher level of care ordered by the requesting physician, and that the alternatives offered by the plans were not clinically sufficient to meet the patients’ needs.
Post-acute services provided in facilities for rehabilitation and skilled nursing care are significantly more expensive than home health services, which may lead to increased scrutiny from MAOs for these types of requests.
The cost of care at SNFs, which provide skilled nursing and therapy services to patients for rehabilitation following inpatient hospital stays was $11,592, compared to home health services, which offered more intermittent SNF care, at $3,089, according to original 2018 Medicare rates.
In one example an organization denied a request to transfer a patient from the hospital to a SNF, stating that a lower level of care [home health services] could meet the beneficiary’s medical needs.
The OIG’s physician panel determined that because of the beneficiary’s deteriorating functional status, comorbidities, and need for daily skilled care, the patient met Medicare coverage requirements for a skilled nursing facility and would benefit from occupational and physical therapy. The MAO reversed this denial upon appeal.
In another example, the OIG’s physician panel determined that the admission to a SNF was medically necessary for an 81-year old patient with a history of dementia, hypertension and was legally blind due to glaucoma, but they were denied because their clinical criteria were not in the Medicare coverage rules.
The physical panel ruled that the beneficiary required physician supervision and should have access to physical and occupational therapy.
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