The Office of the Inspector General (OIG) added a further examination of post-acute care (PAC) prior authorizations (PAs) to its work plan on June 17. LeadingAge and other PAC provider groups met with staff from OIG’s Office of Evaluation and Inspections in March 2024 to discuss the trends and issues our members are experiencing related to Medicare Advantage (MA) plans’ inappropriate PA denials, excessive administrative burden imposed upon providers by these PA processes and plan practices refusing to pay for approved services after their provision.

The Calendar Year 2024 Medicare Advantage policy and technical rule was supposed to limit the use of prior authorizations and reduce the need for additional authorizations to continue medically necessary skilled care but LeadingAge members have seen no change in plan behavior in this regard since the rules took effect. Instead, we continue to observe a broad misunderstanding, or misinterpretations of the Medicare regulations related to the need for skilled care services delivered by skilled nursing facilities and home health agencies. The result, beneficiaries are not receiving care for which they qualify or are inappropriately having the duration of their care shortened, often returning home not yet able to care for themselves.

LeadingAge is pleased to see that its March conversations with OIG staff on these prior authorization concerns have borne fruit and OIG will be digging deeper into MA plan practices related to use of prior authorizations for post-acute care (PAC) settings. OIG will be examining plan processes for reviewing PA requests for PAC services, the extent to which these PA requests are denied and the setting that patients are discharged to following a hospital stay.

Prior OIG research, evaluations, and reports have bolstered our advocacy work in the past. For example, an April 2022 report highlighted what our members have been saying, that plans “issue millions of inappropriate denials each year, and CMS’s annual audits of [Medicare Advantage Organizations (MAOs)] have highlighted widespread and persistent problems related to inappropriate denials of services and payment.” This report brought needed attention to these issues from policymakers by presenting unbiased evidence of the problem.

OIG plans to publish its findings from this next look at PAC PAs in a 2026 report. Also part of the work plan, OIG will be auditing MA plan compliance with federal requirements related to supplemental benefits offered to their enrollees with a report to be issued in 2025.