GAO Report on MA Behavioral Health Prior Authorization

On May 29, the Government Accountability Office (GAO) released a report evaluating how Medicare Advantage (MA) organizations use prior authorization (PA) and internal coverage criteria to determine beneficiary access to behavioral health services, finding that these tools frequently delay care, burden providers, and contribute to access inequities. GAO found that eight out of the nine MA organizations require PA for various behavioral health services, including inpatient psychiatric care, partial hospitalization programs, and specialized services.

Routine outpatient therapy typically did not require PA, and emergency services were generally exempt but often subject to concurrent review. Seven of the eight organizations reported relying on internal coverage criteria for PA decisions rather than CMS guidelines. While the internal criteria sources generally offered more detailed clinical thresholds than Medicare coverage rules, behavioral health providers told GAO that MA organizations applied these criteria inconsistently, even when using the same sources.

GAO also found that CMS provides limited oversight of these practices, specifically not targeting behavioral health services in its program audits or reviews of PA denials, raising concerns about transparency, accountability, and alignment with federal behavioral health priorities. The report recommends that CMS strengthen oversight and improve access for MA enrollees, including targeting behavioral health services in its program audit. CMS stated that it would take the recommendation under advisement.