Medicare Advantage (MA) plans allow Medicare beneficiaries to receive benefits through private plans rather than traditional FFS (Fee for Service) program. Medicare regulations require MA organizations to obtain risk adjustment data required by CMS from the provider, supplier, physician or other practitioner that provided the services. Most MA plans have opted for medical chart reviews to ensure all relevant diagnostic data have been captured in the chart. These programs may utilize medical review service to speed up the review process. MA programs combine commercial insurance practices and Medicare regulations which present a unique set of challenges. These programs use capitated payment models that are based on payment per person rather than payment per service provided. A major concern related to this model is the incentive to inappropriately deny access to or reimbursement for healthcare services with a view to increase profits.
If an MA plan denies coverage for medically necessary care, you can file an appeal. The Office of Inspector General (OIG) says that they will conduct medical record reviews to evaluate the extent to which beneficiaries and providers were denied pre-authorization or payment for medically necessary services covered by Medicare. They will strive to determine the reasons for inappropriate denials and the types of services provided. The OIG points out that between 2014 and 2016, MA plans overturned 75% of their own denials. Providers and enrolees appeal only 1% of the denials.
MA plans had 21 million enrolees in 2017, up from 8 million in 2007. The government has given Advantage plans flexibility that allow them to offer supplemental benefits that are not covered by traditional Medicare. However, unlike traditional Medicare beneficiaries, MA plan enrolees must stay within their plan’s network of providers and also need more referrals to see specialists.
When a denial letter is received, MA plan beneficiaries must read it carefully, understand their rights to appeal and file appeals promptly. Here are the steps to take:
- Ask your treating physician to write a letter clearly outlining why you need the care.
- Understand the timeline to make your claim. MA plan enrolees have only 60 days from the date of the denial, while traditional Medicare beneficiaries have 120 days.
- The MA plan must then make a decision within 30 days if it is denying a service you as a beneficiary have not yet received or within 60 days if it is refusing to pay for a service you have already received. In case your health could be harmed by waiting for the standard appeals process to complete, you can request an expedited appeal that requires a decision within 72 hours.
- If an initial appeal is rejected, the claim is automatically forwarded to an independent entity for review. If your appeal is rejected there, you still have 3 more levels of appeal.
It is important that you receive the coverage promised by your MA plan for medically necessary services. Medicare and Medicaid rules and regulations could be complex and difficult to understand. A Medicare lawyer can assist you to understand the details and help you file an appeal if your claim is denied. The attorney will review your claim to determine the proper course of action. Most attorneys utilize the service of a medical chart review company to review the relevant medical records. With professional legal support, you have more of a chance to successfully appeal the denial.