AHA's letter to the Justice Department cited a recent federal investigation that found Medicare Advantage plans have used prior authorization to deny beneficiaries access to medically necessary care. The association said civil and criminal penalties are necessary to prevent fraud by some Medicare Advantage insurers.

The AHA asked the Justice Department to set up a task force to conduct False Claims Act investigations of insurers that frequently deny care to beneficiaries or payment to providers.

"It is time for the Department of Justice to exercise its False Claims Act authority to both punish those MAOs that have denied Medicare beneficiaries and their providers their rightful coverage and to deter future misdeeds," the letter sent to Acting Assistant Attorney General Brian Boynton said.

The False Claims Act is generally used in healthcare to prosecute providers who submitted a claim for Medicare or Medicaid payment that they know is fraudulent. Healthcare companies paid nearly 90% of fraud settlements collected by the Justice Department in 2021.

When the federal government targets Medicare Advantage insurers for false claims, it's typically because an insurer has been making members appear sicker than they are.

The Supreme Court ruled in 2016 that companies are liable under the False Claims Act if they lied by omission to the government, so long as certain conditions are met. Courts have also ruled that federal healthcare claims are fraudulent if care was provided so...

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