Medicare Advantage Plans Found To Improperly Deny Many Claims



A recent report from the HHS Office of the Inspector General (OIG) raises serious concerns about inappropriate Medicare Advantage denials of care as well as wrongful payment denials. For providers who need to submit claim review requests via paper, one of the specific Claim Review Forms listed below must be utilized. You need to appeal within 60 days of the decision. MA plans are denying claims after clinical validation audits and readmissions within 30 days, said Denise Wilson, vice president of clinical audit and appeal services at AppealMasters.

The process of filing a Medicare appeal depends on what type of plan you have. Call Member Services at 855-442-9940 weekdays, from 7:00 a.m. to 8:00 p.m., and Saturdays, from 9:00 a.m. to 2:00 p.m. The September 25 report details an OIG study undertaken to address concerns that MAOs are inappropriately denying authorization of services for beneficiaries or payments to providers.

The ALJ will generally send you a written decision within 90 days of getting your request. Medicare Advantage enrollment has grown steadily over the past decade and shows no signs of slowing. However, beneficiaries and providers seldom use the appeals process when their claims are denied.

More than half of appeals to Medicare Advantage and prescription drug plans are successful, too. If you requested services or payment from the plan and the plan decided to deny all or part of what you requested, you can ask the plan to reconsider their decision.

The numbers are particularly troubling because of the infrequency with which beneficiaries and providers used the appeals process — for just 1% of denials at the How to Appeal Medicare Advantage Denial initial appeal level, according to the report. Non-contracted providers can request independent review of a claim (i.e. that a person without a financial stake decide whether or not a claim should be paid).

In addition, new flexibilities available in 2019 will allow for expanded supplemental benefits, such as adult day care services, reduced cost sharing, and additional benefits for enrollees with diabetes, congestive heart failure, and other health conditions.

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