HHS OIG has issued an interesting report that affirms how most radiology groups view the prior authorization process.
The OIG report notes that Medicare Advantage Organizations (MAOs) denied payments to providers for some services that OIG believes met both Medicare coverage rules and MAO billing rules. Examples cited by the OIG included advanced imaging services (e.g., MRIs).
OIG reports that among the 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 (also known as Medicare fee-for-service). We identified two common causes of these denials. First, MAOs used clinical criteria that are not contained in Medicare coverage rules (e.g., requiring an x-ray before approving more advanced imaging), which led them to deny requests for services that our physician reviewers determined were medically necessary. Although our review determined that the requests in these cases did meet Medicare coverage rules, CMS guidance is not sufficiently detailed to determine whether MAOs may deny authorization based on internal MAO clinical criteria that go beyond Medicare coverage rules."
Here is a link to the report:
https://oig.hhs.gov/oei/reports/OEI-09-18-00260.asp------------------------------
Thomas W Greeson
Reed Smith LLP
(703) 517-0495
tgreeson@reedsmith.com------------------------------