On the heels of a report showing that some Medicare Advantage Organizations (MAOs) falsely denied prior authorization requests that met Medicare coverage rules, the American Hospital Association (AHA) is urging the U.S. Department of Justice (DOJ) to establish a task force to conduct False Claims Act investigations into commercial health insurance companies that routinely deny access to services.

On April 28, the U.S. Department of Health and Human Services Office of the Inspector General (OIG) released a report titled, “Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care.” The OIG found that some MAOs have been violating the legal obligation to cover the same services as the original Medicare and not impose additional clinical criteria that are more restrictive than Medicare policies. A random sample of denials from a one-week period in June 2019 revealed that 13 percent of prior authorization denials and 18 percent of payment denials met Medicare coverage rules and should have been granted.

The AHA sent a letter to Acting Assistant Attorney General Brian Boynton on May 19 urging the DOJ to “establish a task force to conduct False Claims Act investigations into commercial health insurance companies that are found to routinely deny patients access to services and deny payments to health care providers.”

The OIG report offers recommendations to solve the issue of improper denials. But while the AHA applauds the recommendations and calls them sensible, the AHA writes “they are not enough. It is time for the Department of Justice to exercise its False Claims Act authority to both punish those MAOs that have denied Medicare beneficiaries and their providers their rightful coverage and to deter future misdeeds. The problem has grown so large — and has lasted for so long — that only the prospect of civil and criminal penalties can adequately prevent the widespread fraud certain MAOs are perpetrating against sick and elderly patients across the country.”

The AHA concludes that the creation of a “Medicare Advantage Fraud Task Force” will ensure the “oldest Americans get the care they need under Medicare Advantage, and commercial insurers can no longer take massive amounts of federal dollars while denying necessary services.”