OIG Report Raises Concerns Over Medicare Advantage Denials

A report released by the Office of the Inspector General (OIG) of the US Department of
Health and Human Services (HHS) found that tens of thousands of patients enrolled in Medicare Advantage (MA) plans are denied necessary care that should be covered under the program. The report also found that MA organizations have denied payments to providers for some approved services, creating a burden for providers.

One example cited in the report is a denied request for facet joint injections in three sections of the spine, incorrectly stating that the number of injections requested exceeded the Medicare coverage limit. The OIG’s physician panel determined that the injections were medically necessary and reasonable given the beneficiary’s medical history and determined that the local coverage determination the MA organization cited did not include a limit on the number of injections per section of the spine per session.

The report recommends that the US Centers for Medicare and Medicaid Services:

• issue guidance on the appropriate use of MA organization clinical criteria in medical necessity reviews,
  
• update its audit protocols to address the identified issues, and
  
• direct MA organizations to take additional steps to address vulnerabilities that can lead to manual review errors and system errors.
  

You can read the complete report here to view other examples of denials involving other spinal procedures and injections.

IPSIS continues to monitor the situation.

You can also help sustain this vital advocacy with your donations. The International Pain and Spine Intervention Society (IPSIS) is a tax exempt organization under US section 501(c)(3) of the Internal Revenue Code. As such, contributions are deductible to the extent allowed by law.