OIG Report – Medicare “Advantage” Organizations Restrict Beneficiary Access to Medically Necessary Services

Published in Complex Rehab on May 18, 2022

By Dan Fedor, director of reimbursement and education for U.S. Rehab.

I’ve written several articles over the past two years on Medicare Advantage (replacement plan) due to the overwhelming number of complaints from HME suppliers regarding denials, underpayments, and delays in payment from many of these plans, in which I like to refer to them as DIS-Advantage Plans or replacement plans. I don’t think we should accept using the word "advantage" as we talk about these plans since that seems to be their marketing team’s goal in misleading Medicare beneficiaries about their plans being an advantage. It’s NOT in most cases, and a recent report from the Office of the Inspector General (OIG) confirms what our industry has been experiencing and has been raising concerns about for several years, and it's only getting worse. Note this report is from data pulled in 2019, so as you can imagine even though it reflects badly on these plans, it’s much worse today.

Here are some bullet points from the OIG report. The full report file is at the end of this article.

Random sample of 250 prior authorization denials and 250 payment denials issued by 15 of the largest MAOs during June 1-7, 2019
Determined that MAOs sometimes delayed or denied Medicare Advantage beneficiaries' access to services, even though the requests met Medicare coverage rules
Denied requests that meet Medicare coverage rules may prevent or delay beneficiaries from receiving medically necessary care and can burden providers
Prior authorization requests that MAOs denied, 13 percent met Medicare coverage rules; in other words, these services likely would have been approved for these beneficiaries under original Medicare

OIG Recommend that CMS:

Issue new guidance on the appropriate use of MAO clinical criteria in medical necessity reviews;
Update its audit protocols to address the issues identified in this report, such as MAO use of clinical criteria and/or examining particular service types; and
Direct MAOs to take additional steps to identify and address vulnerabilities that can lead to manual review errors and system errors

Assisting the Beneficiary when medically necessary services are denied, underpaid, or delayed:

Attempt to work with the Medicare Replacement regarding the issue BUT if that doesn’t work
If the beneficiary is dual eligible and has Medicaid they can change once per quarter to original Medicare FFS (don’t have to wait for open enrollment)
If there is a different Medicare Replacement plan in their area that is a 5 star plan they can change to that company anytime if there are documented issues of being denied services that are medically necessary
Have the beneficiary call Medicare and request to file a formal complaint with details 1-800-Medicare
- What was promised in the policy (the sales pitch)
- What was not provided and when (be specific)
- Indicate they feel they were deceived/mislead by the MA if they feel that way
- Inform Medicare that the Medicare Replacement Plan isn’t DY-NO-MITE as Jimmy JJ Walker leads people to believe
- Request to change to Medicare FFS immediately in order to obtain the medically necessary services needed

This OIG report gives our industry some validation that these Medicare Replacement plans policies ARE negatively impacting Medicare Beneficiaries in receiving medically necessary services. If you encounter this situation, please be sure to notify your congressional representative with specifics and cite this OIG report to support what you are experiencing.

VGM and U.S. Rehab plans to prepare a more formal playbook on this topic as we realize that this is one of the top challenges in our industry.

If you have any questions or comments, please contact me at [email protected] or 570-499-8459.

Full OIG Report Apr 2022

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