AHA to HHS OIG Re: Medicare Advantage Organizations' Use of Prior Authorization for Post-Acute Care

September 17, 2024

The Honorable Christi A. Grimm Inspector General
U.S. Department of Health and Human Services
330 Independence Avenue, SW Washington, DC 20201

Re: Medicare Advantage Organizations' Use of Prior Authorization for Post-Acute Care (Report Number OEI 09-24-00330)

Dear Inspector General Grimm:

On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations and our clinician partners - including more than 270,000 affiliated physicians, two million nurses and other caregivers - and the 43,000 health care leaders who belong to our professional membership groups, the American Hospital Association (AHA) applauds the U.S. Department of Health and Human Services Office of Inspector General (HHS OIG) for your recently announced review of Medicare Advantage Organizations' Use of Prior Authorization for Post-Acute Care.

The AHA continues to be concerned about the policies and practices of certain Medicare Advantage Organizations (MAOs) that impede patient access to care and circumvent rules designed to ensure access and coverage parity between Medicare Advantage (MA) and Traditional Medicare. Hospitals and health systems continue to experience inappropriate denials and delays in care for MA beneficiaries consistent with the concerns raised by prior HHS OIG work that found MAOs sometimes denied prior authorization requests for post-acute care after a qualifying hospital stay even though the requests met Medicare coverage rules. As indicated by the mounting evidence of inappropriate insurer denials and delays of post-acute care services, further scrutiny of these practices is warranted. The AHA strongly supports investigation into and greater oversight of MAO practices, particularly as they pertain to access to post-acute care services.

In the following sections, we describe the experience of referring hospitals and post-acute care providers with problematic MAO practices that inappropriately limit access to Medicare-covered post-acute care services and/or fail to comply with federal rules. As described below, these practices have, in some cases, caused direct and irreversible harm to patients, stymieing their recovery from serious illness or injury and hindering restoration of their functional capabilities. These abusive practices further strain health care delivery system resources and capacity at referring general acute-care hospitals by imposing days- or weeks-long delays in the necessary authorizations to transition patients to the next site of care, while sometimes precluding patient access to post-acute care sites altogether. We hope the experiences of patients, hospitals and health systems shared in this letter will inform your examination of MAO use of prior authorization for post-acute care services. We also hope it will spur greater action to curb practices that harm Medicare beneficiaries and unnecessarily delay timely access to care. On behalf of our members, we would be pleased to serve as a resource for any additional data, examples or information that would be helpful as you conduct your inquiry into this important topic.

We also want to acknowledge not all MA plans are the same; many have active partnerships with providers in service of their shared patients/members and consistently act in good faith to follow the rules. To this end, we believe that enforcement actions should be targeted to MA plans that have a history of suspected or actual violations or whose performance metrics related to appeals, grievances and denials could be indicative of a broader problem warranting investigation. Every effort should be made in carrying out enforcement activities to ensure that undue burden is not placed upon MA plans that consistently act in good faith and adhere to federal rules.

View the details below.

AHA Applauds HHS OIG for Announced Review of Medicare Advantage Organizations' Use of Prior Authorization for Post-Acute Care