Legal experts expect ‘more scrutiny’ of Medicare prior authorization from feds

June 6, 2022
Modern Healthcare
By Maya Goldman

As the federal government’s attention to improper Medicare Advantage prior authorization denials intensifies, insurers should consider examining their policies if they want to avoid trouble.

Hospitals have called on the Justice Department to use the False Claims Act against Medicare Advantage carriers that improperly deny coverage. Health insurance companies ought to take a closer look at their policies and how employees are trained to implement them, said Scott Stein, a partner at Sidley Austin and editor of the law firm’s False Claims Act blog.

“I do suspect that there’s going to be a lot more scrutiny in this area,” Stein said.

The False Claims Act is generally enforced against providers that knowingly submit fraudulent claims to Medicare or Medicaid. Whether the statute also governs prior authorization denials is up for debate.

Even for situations in which it could apply, evidence that the denials and the appeals processes were so egregious that they go beyond contract violations would have to be strong, said Jason Christ, a healthcare fraud and abuse attorney at Epstein Becker Green.

But federal interest in Medicare Advantage enforcement follows a familiar pattern that often ends with the Justice Department getting involved.