Better Medicare Alliance Responds to OIG Report on Prior Authorization Use in Medicare Advantage

Washington, D.C.  – Better Medicare Alliance, the nation’s leading research and advocacy organization supporting Medicare Advantage, responded today to a U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) report on prior authorization use in Medicare Advantage. 

“Medicare Advantage is delivering high-quality, coordinated care to more than 28.5 million diverse beneficiaries – saving them nearly $2,000 per year, driving better health outcomes, and delivering a 94% beneficiary satisfaction rate,” said Mary Beth Donahue, President and CEO of the Better Medicare Alliance. “The use of medical management tools, including prior authorization, is one way that Medicare Advantage ensures beneficiaries receive the right care, in the right setting, and at the right time.”

Donahue added, “While this study represents only a narrow sample of Medicare Advantage beneficiaries and polling data shows that less than half of Medicare Advantage beneficiaries have ever experienced a prior authorization themselves, Better Medicare Alliance has strongly supported efforts to streamline and simplify the prior authorization process for patients and providers. We look forward to our continued work with policymakers to strengthen Medicare Advantage for today’s seniors and tomorrow’s enrollees.”

Background:

• OIG’s report found that nearly 9 in 10 prior authorization coverage denials were consistent with Medicare coverage rules and more than 8 in 10 denials for payment requests met Medicare billing rules. Moreover, OIG found that Medicare Advantage plans approve “the vast majority of prior authorization requests and provider payment requests.”
• A June 2021 poll shows that less than half of seniors on Medicare Advantage say that they have ever encountered a prior authorization. Only 6% of seniors on Medicare Advantage say they have encountered prior authorizations “often.” Even among the minority of Medicare Advantage beneficiaries who have encountered prior authorizations, 66% say it imposes no burden to them at all.
• Medicare Advantage plans are held accountable for efficiently adjudicating prior authorizations and ensuring timely access to care through CMS’s Star Ratings system. CMS reported in October that “Approximately 90 percent of people currently in Medicare Advantage plans that offer prescription drug coverage are enrolled in a plan that earned four or more stars in 2022. The number of plans with a rating of 4 or more stars is higher for 2022 compared to last year.”
• A December 2021 poll shows Medicare Advantage with a 94% beneficiary satisfaction rate while 88% of beneficiaries agree that “Medicare Advantage lets them see the doctors they want on their own terms.” Likewise, the latest Medicare Current Beneficiary Survey (MCBS) data shows that 94.9% of Medicare Advantage beneficiaries are satisfied with health care quality and 95.6% are satisfied with their ease of getting to their doctor.

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