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Inappropriate Medicare Advantage care denials appear widespread

Written by Diane Archer

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. It shows that Medicare Advantage plans, commercial health plans that contract with Medicare to deliver Medicare benefits, overturn their own denial decisions 75 percent of the time. Unfortunately, most people do not appeal their denials.

The OIG report suggests that Medicare Advantage plans are likely inappropriately issuing denials many millions of times a year. The data show that only one percent of Medicare Advantage plan members appealed their denials between 2014 and 2016. And, even with such a small fraction of their members appealing, Medicare Advantage plans overturned 532,000 denials of care or payment–three out of four of these denials–over the two-year period.

Put differently, 99 percent of Medicare Advantage plan members, who were denied access to care or payment for services they received, did not challenge their denials. They likely did not understand that they have a right to appeal or that it is an easy process. Had they appealed, there is good reason to believe that three out of four of them would have won their appeals.

Centers for Medicare & Medicaid Services (CMS)  audits of Medicare Advantage plans support the OIG’s findings that many Medicare Advantage plan members may not be getting the care or coverage to which they are entitled. CMS has found profound and persisting problems with Medicare Advantage plans wrongly not paying for care or not approving care. In 2015 alone, CMS found that more than half of the Medicare Advantage plans they audited (56 percent) inappropriately denied care or payment.

In addition, in its audits of Medicare Advantage plans, CMS found that more than four in 10 Medicare Advantage plans (45 percent) did not provide their members with appropriate or correct information about their denials, undermining their members’ ability to challenge them. CMS penalized these Medicare Advantage plans, but the punishment has not deterred them from continuing to wrongly issue denials.

The OIG recommends that CMS take stronger action against Medicare Advantage plans. In addition, it notes that even when CMS audits show widespread wrongful denials by Medicare Advantage plans, they do not affect a Medicare Advantage plan’s star ratings. As a result, these star ratings have little if any value for individuals choosing among Medicare Advantage plans. Moreover, health plans that CMS sanctions can also receive quality bonus payments.

Whenever you receive a denial from your Medicare Advantage plan, you should fight back. You have a high likelihood of winning. It’s a simple process and it’s free.

If you are trying to evaluate differences among Medicare Advantage plans, do not rely on the star ratings. Avoid plans sanctioned by CMS, which is noted on the Medicare Plan Finder web site.

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  • Only one percent of Medicare Advantage plan members appealed their denials between 2014 – 2015. Medicare advantage plans overturned 532,000 denials of care or payment, in those two years. That was 3/4 of the denials. I assume that the denials that were overturned, were appealed. This is fuzzy math. If 532,000 is 3/4 of a percent, then the denials would be in the area of 66,500,000. Each Medicare Advantage plan member would have an average of hundreds of denials.

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