High Numbers of Successful Appeals for Denied Medicare Advantage Claims Raise Concerns

Almost 37% of all Medicare beneficiaries will be enrolled in Medicare Advantage plans in 2019, according to CMS projections.


However, despite all the extra benefits and low premiums, not everything may be as rosy with Medicare Advantage plans as CMS might lead one to believe through their press releases ( such as the one published September 28, 2018 ) and promotions of the plans.

According to a study published in September 2018 by the Office of Inspector General,

56% of Medicare Advantage Organizations (MAOs) inappropriately denied requests for preauthorization of services and/or payment. This could have been due to making the wrong clinical decisions or not conducting appropriate outreach before making clinical decisions.

In fact, about 75% of denials were overturned by the MAOs themselves during the first level of appeals. After the four levels of the independent review process, that number increases to about 90%.

"High numbers of overturned denials upon appeal, and persistent performance problems identified by CMS audits, raise concerns that some beneficiaries and providers may not be getting services and payment that Medicare Advantage Organizations (MAOs) are required to provide."

The appeals process for Medicare beneficiaries

The appeals process for Medicare beneficiaries

With the very high rates of enrollment, even seemingly low rates of inappropriate denials can create significant problems for Medicare beneficiaries and their providers said the report.

High denials place a burden on the beneficiary to take steps to appeal claims. In fact, less than 1% of the total number of denials issued each year will be appealed. The end result then is that beneficiaries will go without the requested service or pay for the service out of pocket unnecessarily.

Are you enrolled in a Medicare Advantage plan?

If you are enrolled in a Medicare Advantage plan and think that you've had an inappropriate claim denial, take steps to appeal the claim.

If you choose to move from a Medicare Advantage plan to Medicare Parts A and B with a Medicare Supplement, please know that you may have to go through medical underwriting before getting a Supplement policy. This means, if you have any pre-existing medical conditions, you may not be able to get this type of coverage.