The American Hospital Association (AHA) wants the federal government to launch a series of probes into commercial payers that routinely deny access to care and services.
The hospital group wrote (PDF) to the Department of Justice (DOJ) last week pressing for False Claims Act investigations after a recent report from a federal watchdog found some Medicare Advantage (MA) plans have used prior authorization to deny care in violation of Medicare coverage rules. The agency also pressed (PDF) the Centers for Medicare & Medicaid Services (CMS) to weigh in.
“This problem has grown so large—and has lasted for so long—that only the prospect of civil and criminal penalties can adequately prevent the widespread fraud certain [Medicare Advantage organizations] are perpetrating against sick and elderly patients across the country,” the letter said.
AHA was referring to a report from Department of Health and Human Services’ (HHS') Office of Inspector General (OIG) last month. OIG looked at a random sample of 250 prior authorization denials made by 15 major insurers back in 2019. It found that only 13% of the denials followed Medicare coverage requirements and so did only 18% of the payment denials.
OIG wanted CMS to deliver guidance on appropriate clinical criteria and to update audit protocols to flag errors.
The report is the latest in a long-standing feud between payers and providers over prior authorization, which requires providers to get permission from insurers to administer...
SPRINGFIELD – The Illinois Education Association (IEA) is working to pass Senate Bill 2914 this session, a bill that would put an end to a long-time practice of school administrators keeping accus...