Need costly care in Medicare Advantage? Expect a denial

While every Medicare Advantage plan is different, the data on Medicare Advantage plan denials suggest that the odds are high of being denied costly care, particularly post-hospital care. The data also show that enrollees tend to prevail when they appeal these denials, suggesting that the denials were inappropriate. In a new KFF issue brief, researchers make the case that we need data on which plans are denying care at high rates.

Whatever reasons exist for allowing insurers not to provide data on denial rates for each Medicare Advantage plan, they pale in comparison to knowing which Medicare Advantage plans are inappropriately refusing to cover their enrollees’ rehabilitative and skilled nursing care. Without this information, people enrolling in a Medicare Advantage plan cannot avoid bad actor plans. And, they are forced to gamble on their long-term health and, sometimes, their lives.

Overall, Medicare Advantage plans deny 65% of requests for long-term care hospital stays (LTCHs) and 54% of requests for stays in inpatient rehabilitation facilities (IRFs). These are extremely costly and extremely important treatments for people post-hospitalization.

People needing LTCH stays, tend to require respiratory therapy, treatment for head traumas and pain management. People needing IRF stays tend to need serious rehabilitation after strokes and brain injuries. A five or six-day delay–which is not unusual in Medicare Advantage–could endanger their health. It could also mean more hospital copays while they await transfer.

People who appeal their LTCH and IRF denials prevail much of the time. It is an easy process, well worth doing. But, the only good solution is to punish Medicare Advantage plans with high denial rates, cancelling their contracts or, at the very least, penalizing them financially in a meaningful way.

Here’s more from Just Care:

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