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Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care

Submitting OIG: 
Department of Health & Human Services OIG
Date Issued: 
Wednesday, April 27, 2022
Agency Reviewed / Investigated: 
Department of Health & Human Services
Submitting OIG-Specific Report Number: 
OEI-09-18-00260
Component, if applicable: 
Centers for Medicare & Medicaid Services
Centers for Medicare and Medicaid Services
Location(s): 
United States
Type of Report: 
Inspection / Evaluation
Questioned Costs: 
$0
Funds for Better Use: 
$0
Number of Recommendations: 
3
View Document: 
AttachmentSize
PDF icon OEI-09-18-00260.pdf944.71 KB

Related Open Recommendations

Recommendation Number Recommendation Status Significant Recommendation Additional Details
22-E-09-015.01 Open No
CMS should Issue new guidance on the appropriate use of MAO clinical criteria in medical necessity reviews.
22-E-09-015.02 Open No
CMS should Update its audit protocols to address the issues identified in this report, such as MAO use of clinical criteria, and/or examine particular service types.
22-E-09-015.03 Open No
CMS should direct MAOs to take additional steps to identify and address vulnerabilities that can lead to manual review errors and system errors.
Displaying 3 of 3 Recommendations