Insurance
HHS Inspector General finds Medicare Advantage plans inappropriately denying services and payment
When beneficiaries and physician groups appealed preauthorization and payment denials, Medicare Advantage plans overturned 75 percent of denials during 2014-16, amounting to approximately 216,000 denials each year. What’s even more concerning is that beneficiaries and providers only appeared 1% of denials, indicating the number of overturned denials would likely be much higher had more appeals been filed. HHS OIG warns, “[t]he 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.” As a result, the OIG recommended CMS significantly increase enforcement action against Medicare Advantage plans and address persistent problems related to inappropriate denials and insufficient denial letters in Medicare Advantage.
