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HHS OIG Report Finds Medicare Advantage Organizations (MAOs) Are Not Providing Services and Payment Required by Law

Recently, the HHS Office of Inspector General (OIG) released a report, “Medicare Advantage Appeal Outcomes and Audit Findings Raise Concerns About Service and Payment Denials,” that found providers and Medicare beneficiaries may not be receiving reimbursement or services that Medicare Advantage Organizations (MAOs) are required to provide. Approximately 75% of MAOs denials during 2014 to 2016 were reversed when beneficiaries and providers appealed preauthorization and payment denials. This is particularly alarming because it suggests that Medicare Advantage beneficiaries and providers were initially denied services and payments that should have been provided. The OIG recommends that CMS, “(1) enhance its oversight of MAO contracts, including those with extremely high overturn rates and/or low appeal rates, and take corrective action as appropriate; (2) address persistent problems related to inappropriate denials and insufficient denial letters in Medicare Advantage; and (3) provide beneficiaries with clear, easily accessible information about serious violations by MAOs.” CMS has agreed to comply with these recommendations.

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