HHS OIG Report Raises Concerns About Medicare Advantage Step Therapy

The Department of Health and Human Services (HHS) Office of Inspector General (OIG) has issued a report that raises concerns about the beneficiary impact of the Centers for Medicare & Medicaid Services’ (CMS) new “fail first” step therapy policy for Medicare Advantage (MA) beneficiaries beginning in 2019. The report's findings include:

• A “central concern” in the MA program is that planshave “potential incentives” to “inappropriately deny access to services and payment in an attempt to increase their own profit.”
• 75%of MA plans’ coverage or payment denials were overturned at the first level of appeal, and additional denials were overturned in later stages of appeal.
• Treatment disruptions and coverage delays that are already regularly taking place in the MA program will be exacerbated under the new “fail first” policy.
• Beneficiaries and providers appealed only one percent of denials by MA plans, which may be due to the “confusing and overwhelming” process for many beneficiaries.
• MA plans’ inaccurate coverage denials are particularly difficult for the MA patient population, finding that treatment delays “may be especially burdensome for beneficiaries with urgent health conditions.”

Read the full HHS OIG report here.

Posted 10/2/18