Medicare Advantage Overturns 75% Of Its Own Claim Denials



No one likes to find out that their Medicare claim has been denied. At Level 2, the Independent Review Organization reviews our plan's decision and determines if it is correct or if it should be changed. CMS audits have found lingering issues related to denials of care and payment from 2012 to 2016. For example, ask her or him if there is evidence-based literature supporting use of the treatment that should have been taken into account by your Advantage plan,” says Ruth Linden, founder of Tree of Life Health Advocates in San Francisco.

If Medicare, your Medicare Advantage Plan (or other type of Medicare health plan), or your prescription drug plan denies you coverage for something you believe is necessary for your health, you can appeal the decision. IMPORTANT: For all appeals, ask your doctor to write a letter of support explaining why you need the service that was denied.

Put differently, 99 percent of Medicare Advantage plan members, who were denied access to care or payment for services they received, did not challenge their denials. When denied claims are received by F&W, our attorneys will review your contract with the MA provider to ensure that all avenues for appeal are being utilized.

In some cases, the ratio of denials to appeals was drastic. Call 1-800-MEDICARE to request the telephone number of your State Health Insurance Assistance Program. Make sure to file your appeal within 60 days of the date on the notice. We collected data on denials, appeals, and appeal outcomes for 2014-16 at each level of the Medicare Advantage appeals process.

In addition, in its audits of Medicare Advantage plans, CMS found that more than four in 10 Medicare Advantage plans (45 percent) did not provide their members with appropriate or correct information about their denials, undermining their members' ability to challenge them.

If you are filing an expedited appeal, OMHA should issue a decision within 10 days. Learn more about the medical appeals process by reviewing your Evidence How to Appeal Medicare Advantage Denial of Coverage (EOC). You can get an expedited review whenever you're discharged (or services are stopped) from an inpatient hospital, skilled nursing facility, home health agency, comprehensive outpatient rehabilitation facility, or hospice.

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