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Coverage Denials by Private Medicare Plans Spur Calls for Change (1)

April 28, 2022, 7:05 PMUpdated: April 29, 2022, 3:38 PM

A federal watchdog agency wants the Centers for Medicare & Medicaid Services to issue new regulations and update its audit protocols to address the improper denial of prior authorization and payment requests by Medicare managed care plans.

A report by the Health and Human Services Office of Inspector General found that 13% of prior authorization requests denied by private Medicare Advantage plans actually met Medicare coverage rules. These plans, which provide program benefits for roughly 27 million beneficiaries, sometimes denied or delayed payments to physicians and other clinicians for care they had delivered that met program coverage and billing rules, ...