AHA Urges CMS to Hold Medicare Advantage Plans Accountable

May 19, 2022

May 19, 2022

The Honorable Chiquita Brooks-LaSure
Administrator Centers for Medicare & Medicaid Services
7500 Security Blvd
Baltimore, MD 21244

Re: U.S. Department of Health and Human Services Office of Inspector General Report: Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns about Beneficiary Access to Medically Necessary Care

Dear Administrator Brooks-LaSure:

On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations and our clinician partners - including 3,000 post-acute care (PAC) providers, more than 270,000 affiliated physicians, two million nurses and other caregivers - and the 43,000 health care leaders who belong to our professional membership groups, the American Hospital Association (AHA) urges CMS to take swift action to hold Medicare Advantage (MA) plans accountable for inappropriately and illegally restricting beneficiary access to medically necessary care.

Inappropriate and excessive denials for prior authorization and coverage of medically necessary services is a pervasive problem among certain plans in the MA program. This results in delays in care, wasteful and potentially dangerous utilization of fail-first imaging and therapies, and other direct patient harms. In addition, they add financial burden and strain on the health care system through inappropriate payment denials and increased staffing and technology costs to comply with plan requirements. These harms are evidenced by the striking report issued last month by the Department of Health and Human Services' Office of Inspector General (HHS-OIG) entitled "Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care."1 As evidenced by the findings, problems with MA plan utilization management and coverage policies have grown so large-and have lasted for so long-that strong, decisive, and immediate enforcement action is needed to remedy the harm that certain MA plans are perpetrating against sick and elderly patients, the providers who care for them, and American taxpayers, who currently pay MA plans more to administer Medicare benefits to enrollees than they would to the traditional Medicare program.

View the detailed letter below.