OBJECTIVE
Medicare Advantage plans must cover at least the same services as original Medicare, but Medicare Advantage Organizations (MAOs) may impose additional administrative requirements, such as requiring prior authorization before certain services can be provided. Prior OIG work found that MAOs sometimes denied prior authorization requests for post-acute care after a qualifying hospital stay even though the requests met Medicare coverage rules. We will review the extent to which selected MAOs denied requests for post-acute care in long-term acute care hospitals, inpatient rehabilitation facilities, and skilled nursing facilities, and the extent to which denied requests were appealed and overturned. We will also conduct medical record reviews for a sample of cases to determine the extent to which MAOs denied requests for post-acute care admissions that met Medicare coverage rules.
There are three projects in this series.
There are 3 projects in this series.
Project titles will remain unpublished until projects are complete and reports are posted.
ACTIVE PROJECTS IN THIS SERIES (3)
Medicare Advantage Organizations’ Use of Prior Authorization for Post-Acute Care
TIMELINE
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June 17, 2024Series Number SRS-E-26-004 Assigned
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June 17, 2024Projects Announced
Project OEI-09-24-00330
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Project OEI-09-24-00331
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May 15, 2026Project Announced
Medicare Advantage Organizations’ Use of Prior Authorization for Post-Acute Care - OEI-09-24-00332
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Today3 Evaluations In-Progress
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Est FY2026Estimated Fiscal Year for Series Completion