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WHAT YOU NEED TO KNOW. A just-published report from the Department of Health and Human Services Office of Inspector General (OIG) finds that Medicare Advantage (MA) plans sometimes delayed or denied coverage for Medicare-covered services.
The report found that such delays or denials could result in negative health outcomes and increase costs that burdening plan participants.
The study looked at 12,273 denials of requests for services during the first week of June 2019. Annualized, the report projects 84,812 beneficiary requests for services that met Medicare coverage rules would be denied that year.
And, it’s important to note that Medicare Advantage plans provide excellent coverage and benefits. Indeed, some 26 million Americans are now covered by an MA plan. You’ve undoubtedly seen the numerous television ads featuring celebrity spokespeople touting all sorts of free benefits and features.
13% of the prior authorization denials met Medicare coverage rules and would have been covered if the beneficiary had been in traditional Medicare (or one assumes a Medigap policy).
MA plans are permitted to have their own coverage rules but must be “no more restrictive than original Medicare.” However, when experts reviewed the sample cases, they determined that MA plans used additional medical criteria for their decisions and required more documentation than needed to demonstrate medical necessity.
The Office of Inspector General found that three service types were very commonly represented among the denials:
1. Advanced imaging like MRIs and CT scans,
2. Care in nursing or rehabilitation facilities after hospitalization,
Click here to Access The Full Report
GOOD NEWS: PRIOR STUDY FINDS DENIED CLAIMS ARE OVERTURNED
A September 2018 OIG report found that when beneficiaries and providers appealed denied requests in Medicare Advantage plans (2014−2016), about 75 percent were overtuned.
The report urged that the matter be addressed in light of the millions of Americans with Medicare Advantage coverage. Good news for all. Medicare Advantage plans deny claims is not a great headline for any report to lead with.
The American Association for Medicare Supplement Insurance encourages you to connect with your local Medicare insurance agent. While Medicare is a national program, available plan choices can be different from one town (or Zip Code) to the next.
ABOUT THE AMERICAN ASSOCIATION FOR MEDICARE SUPPLEMENT INSURANCE
We are a national organization that advocates for the importance of Medicare insurance solutions and supports insurance professionals who market Medicare Supplement (Medigap) as well as Medicare Advantage protection. AAMSI does not sell insurance. Neither do we offer or provide any legal or finacial advice. For that we recommend you work with a local professional, be that an insurance agent, a CPA or lawyer.