Medicare Advantage Plans Denying Needed Care

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By Lindsay Malzone

Medicare Advantage plans are known for their robust benefits and additional coverages that Traditional Medicare doesn’t offer. While most beneficiaries that enroll in a Medicare Part C option are happy with their coverage, there are times when services are denied. 

More than 28 million Medicare beneficiaries are enrolled in Medicare Advantage plans. There are bound to be errors and mistakes. We need to have better systems in place to catch these and make sure our seniors are getting the service they need. 

What is Medicare Advantage?

Medicare Advantage plans are another way to receive your Medicare benefits. These plans include your Medicare Parts A and B benefits, and in most cases also include your Part D prescription benefits. These all-in-one plans typically have low to no premiums and fixed copays for most services. 

How is it different from Original Medicare?

Original Medicare allows you to see any healthcare provider that accepts Medicare without the need for referrals. Medicare Advantage plans are network-based plans that are required to have coverage as good or better than Traditional Medicare. 

Unlike Original Medicare, Medicare Part C plans are required to have a maximum out-of-pocket to cap the cost for the beneficiary. They also can include benefits that aren’t covered by Medicare such as gym memberships, dental, vision, and hearing coverages. Medicare doesn’t have network restrictions 

Why are qualified beneficiaries being wrongfully denied necessary care?

Recently the inspector general’s office for the Department of Health and Human Services has released a report outlining some of these cases and calls for better oversight of Medicare Part C plans. In the report, 13% of cases that were denied were considered medically necessary services. 

The popularity of Medicare Advantage plans is growing rapidly more popular, and this shows a problem that needs to be addressed and resolved. Some of the items that plans denied included wrongfully denied prior authorization and payment requests for a variety of reasons. 

Most Common Denial Reasons include:

  • Internal clinical criteria are not listed in Medicare coverage rules.
  • Manual review errors
  • Unnecessary documentation requests when the necessary documentation was already in the patient’s medical records and files. 
  • System errors

Most Common Services Denied Include:

  • MRIs
  • CT Scan
  • Skilled nursing after surgeries or hospitalization

What can someone do if their care is denied?

While errors do occur, there is an appeals process and many doctors and Medicare beneficiaries have already begun filing appeals to fight denials of coverage. Medicare is reviewing the findings of the report to determine appropriate actions.

You’ll receive instructions on how to appeal the decision in your provider’s initial denial letter and plan materials. You have 60 days from notification to file your appeal. If you miss the deadline, you must provide the reason for applying for the appeal late. 

Medicare outlines four steps to take before you file your appeal.

  1. Get help: You can get help filing the appeal if you choose. You can contact your local  State Health Insurance Assistance Program (SHIP) for assistance or appoint a representative. You could appoint a family member, friend, advocate, attorney, doctor, or someone else to be your representative.
  2. Gather information: Get as much of the information from your doctor, other healthcare providers, or supplier.
  3. Keep copies: Keep a copy of all correspondence you send and receive from your plan.
  4. Start the process: Follow the directions in your plan’s initial denial notice and plan materials. 

Once the appeals process begins, you’re entitled to disagree with and decision at any level of the process and escalate to the next level. 

While Medicare Advantage plans are growing in popularity, they aren’t perfect. Additional oversight is needed to ensure our Medicare beneficiaries are properly cared for. If you or a loved one feel like you were wrongfully denied the proper healthcare services don’t hesitate to start the appeals process. You can counsel your insurance agent, or doctor if you feel like you have been wrongfully denied.

Lindsay Malzone is a Medicare Expert at Medigap.com.