Medicare Advantage participants should appeal denial of claim
The bad news is “a new report by federal investigators finds that [Medicare] Advantage plans have a pattern of inappropriately denying patient claims.”
“The good news is that those denials are frequently overturned if people bother to appeal.”
“The [Medicare] Advantage payment model reimburses plans a pre-set amount per patient, and this may be incentivizing plans “to deny preauthorization of services for beneficiaries, and payments to providers, in order to increase profits,” concludes the report, which was conducted by the Office of Inspector General (OIG) at the U.S. Department of Health and Human Services.”
“The OIG report, which looked at appeals filed by patients and healthcare providers from 2014 through 2016, found that when denied claims were appealed, the [Medicare] Advantage plans themselves overturned those denials 75 percent of the time.”
“The findings are worrisome because very few claim denials are appealed – just 1 percent during the three-year period reviewed in the OIG report. That suggests that patients who do not appeal claims are going without the requested services, or may have paid out of pocket. It also means the provider may not have been paid.”
“Medicare evaluates the performance of private plans and uses a five-star rating system, with five being the best rating. Officials encourage beneficiaries to consider the ratings when selecting a plan.
But federal investigators questioned the usefulness of the ratings as a tool for beneficiaries. Health plans cited for serious violations of Medicare rules “can still receive high star ratings” and the bonus payments that go along with high grades, the inspector general reported.
Beginning in 2019, the report said, “audit violations will no longer be reflected in star ratings.”