Medicare advantage plans often deny coverage for eligible, necessary care, says report (18% of refused claims should have been approved—Appeal your claim!)

Medical Xpress / Healthday / U.S. Department of Health and Human Services ^ | Apr. 28, 2022 | Rosemary Bartholomew, Inspector General’s Office, U.S. Department of Health and Human Services

[ConservativeMind]

Coverage for eligible, necessary care is denied each year to tens of thousands of seniors with private Medicare Advantage plans, U.S. federal investigators say.

In a report released Thursday, the team from the inspector general's office of the U.S. Department of Health and Human Services said Medicare needs to improve oversight of these plans and strengthen enforcement against those private insurance companies with a pattern of improper denials of coverage.

About 28 million older people have Medicare Advantage plans, which offer privatized versions of Medicare that are often cheaper and provide a greater range of benefits than the traditional government program.

Instead, the investigators said they found "widespread and persistent problems related to inappropriate denials of services and payment."

Their review of 430 denials by Medicare Advantage plans in June 2019 revealed that 13% of cases where care was denied for medical services were actually medically necessary and should have been covered. Based on that rate, the investigators estimated as many as 85,000 requests for prior authorization of medical care were potentially improperly denied in 2019.

The report also said that Advantage plans refused to pay about 18% of legitimate claims, about 1.5 million payments, in 2019. In some cases, plans ignored prior authorizations or other documentation to support the payment.

The most frequent denials included those for MRIs and CT scans. In one case, an Advantage plan refused to approve a follow-up MRI to determine whether a lesion was malignant.

Clearly, these denials may delay or prevent a Medicare Advantage beneficiary from receiving needed care, according to report team leader Rosemary Bartholomew. Few patients or providers try to appeal these decisions, she noted.

A 2018 report by the HHS inspector general's office found that private plans reversed about three-quarters of their denials on appeal.

[ConservativeMind]

Gather your paperwork and fight back with your insurer.

They are wrong nearly 20% of the time on the denied claims.

[ConservativeMind]

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[thinden]

Thanx for posting this info

[napscoordinator]

You get what you pay for. Why should everything be covered when most get 177 dollars returned a month plus all sorts of other goodies. I think paying some of the medical costs is appropriate.

[metmom]

I ***HATE*** Medicare.

[Adder]

that are often cheaper and provide a greater range of benefits than the traditional government...

Sure...if you are not going to pay claims, cheaper is great.

[mewzilla]

Meanwhile, Deep State plans on forgiving student loans, pitting generations against one another.