Medicare Advantage Plans Hit Back at Report on Coverage Denials

"The main concern about many of those cases was not that they were improper, but rather than more guidance from the government was needed on criteria that plans can use to make coverage determinations," AHIP said.

Physicians' View

The American Medical Association — a Chicago-based group that represents physicians — said it agrees with the HHS OIG Report.

"An investigation by the inspector general's office of the Health and Human Services Department into the inappropriate use of prior authorization by Medicare Advantage plans uncovered information that mirrors physician experiences," the AMA said.

"Surveys of physicians have consistently found that excessive authorization controls required by health insurers are persistently responsible for serious harm when necessary medical care is delayed, denied, or disrupted," the AMA added. "The American Medical Association agrees with the federal investigators' recommendations for preventing inappropriate use of authorization controls to delay, deny and disrupt patient care."

AHIP Defends Preauthorization Programs

AHIP argued that preauthorization program can keep patients from getting dangerous, unnecessarily expensive or unnecessary care.

Many physicians have estimated that 15% to 30% of medical care is unnecessary, and preauthorization programs can reduce use of unnecessary care, AHIP said.

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