Medicare Advantage Denials

I have been a health insurance broker for over a decade and every day I read more and more "horror" stories that are posted on the Internet regarding health insurance companies not paying claims, refusing to cover specific illnesses and physicians not getting reimbursed for medical services. In 2016, the MAOs analyzed by the federal watchdog collectively denied 8 percent of payment requests from providers and 4 percent of prior authorization requests for services from beneficiaries. In the network portion of a PPO, some in-network medical services are covered only if your doctor or other network provider gets prior authorization from our plan.

The report from the Inspector General comes amid increasing scrutiny of Medicare Advantage organizations for potentially overcharging the government for services. You must file the request for reconsideration with the appropriate QIC within 180 days of the date you got the redetermination.

Remember you are only appealing the date of service in question, the place of service, and the medical provider. At Level 2, the Independent Review Organization reviews our plan's decision to determine if it is correct or if it should be changed. You have certain appeal rights if coverage is denied, including coverage of a prescription drug you need.

Denials are routinely given "rubber stamps" at the first two levels of appeal, the lawsuit claims. On February 22, 2017, CMS released the HPMS memorandum entitled, Updated Guidance on Outreach for Information to Support Coverage Decisions.” A copy of the memo is available in the Downloads” section below.

About 75 percent of appeals are successful at the first level of review. If your Medicare Advantage plan has denied you services or withheld reimbursement for medical expenses, you can appeal the decision to the Office of Medicare Hearings and Appeals. You also have the right to request a fast-track appeal through HSAG if your Medicare Advantage coverage for services in a skilled nursing facility, home health care agency or a comprehensive rehabilitation facility are about to end.

The Office of Medicare Hearings and Appeals (OMHA) handles these appeals. Every Medicare Advantage plan must provide Medicare Part A (hospital insurance) and Part B (medical insurance) to its How to Appeal Medicare Advantage Denial members. If your Medicare Advantage plan does not reverse its denial, the appeal must be forwarded to an Independent Review Entity (IRE) within 24 hours by the MA plan.