Fighting Denied Medicare Advantage Claims

Insurance companies are in business to make money and part of that process routinely includes turning down payment for medically necessary care.  What a lot of people seniors don't realize is that if they file an appeal, the odds are good that the plan will overturn its decision.

This is based on a recent government report that examined the service and payment denials in Medicare Advantage plans, which are offered by private insurance companies and often combine basic Medicare, drug, dental and vision coverage into a single package.   Looking at the appeals file with these plans between 2014 and 2016, the U.S. Department of Health and Human Services' Office of Inspector General found they overturned 75% of their own denials.

"The high number of overturned denials raises concerns that some Medicare Advantage beneficiaries and providers were initially denied services and payments that should have been provided," the report says.  The Inspector Generals also determined that enrollees and providers appealed only 1% of denials, suggesting that some people may be going without needed services or paying out of pocket for their needs.

These denials may also affect the relationship between patient and doctor. "If a provider is denied payment, they may be more reticent to provide certain services" in the future, says Leslie Fried, senior director at the National Council on Aging's Center for Benefits Access.

As the number of Medicare Advantage plan members soars (8 million in 2007 to 22 million in 2019), these denials are a growing concern.  As the government continues to give more flexibility to Advantage plan, such as allowing them to offer additional benefits not covered by traditional Medicare, these plans will become more inviting to join.  

"Medicare Advantage plans are committed to providing quality, affordability and appropriate care to patients," says Cathryn Donaldson, a spokesperson for America's Health Insurance Plans - a health insurance industry group.  A denial, she says, "can often be a request for additional information for the claim, or a move to an alternative treatment that's more effective."

How to Deal With a Denial

The first and most important thing to do for Advantage plan members is to read their denial notices carefully, understand their right to appeal and then file their appeal promptly, patient advocates say.

But denial notices sent to enrollees aren't always clear.  In 2015, audits done by the Centers for Medicare and Medicaid Services found 45% of Advantage plans sent denial letters with incomplete or incorrect information, according to the Inspector General's report.  45%.

Follow the instructions on the denial notice when making your appeal.  Ask your doctor to write a letter explaining why you need the care. Be sure to understand the time-line to make your claim, because some enrollees have only 60 days from the date of the denial notice to file an appeal, compared to the 120 days to appeal  to traditional Medicare.   The plan then has 30 days to make a decision if denying a pre-authorization or 60 days if it is refusing to pay for a service you have already received.  If your health could be harmed by waiting for this procedure to take its due course, you should request an expedited appeal, which requires a decision within 72 hours.

If your insurance provider rejects your first appeal, your claim is automatically forwarded to an independent entity for review.  If your appeal is rejected there, you still have up to three more levels of appeal you can use.

How to Get Help

For patients who are sick or frail, this process can be a bit overwhelming.  Here are some resources to help:

Your State Health Insurance Assistance Program.
Find your local program at (877-839-2675)

Legal Aid Programs.
Find services in your area at (800-677-1116)

Medicare Rights Center.
An advocacy group for Medicare beneficiaries at (800-333-4114)