Fight a Denied Medicare Advantage Claim

If a Medicare Advantage plan denies you coverage for medically necessary care, don’t take it lying down. File an appeal, and your odds are good that the plan will overturn its decision.

That’s the message for consumers in a recent government report examining service and payment denials in Medicare Advantage plans, which are offered by private insurers and often combine basic Medicare benefits with drug, dental and vision coverage in a single package. Looking at appeals filed by Advantage enrollees and health care providers between 2014 and 2016, the U.S. Department of Health and Human Services’ Office of Inspector General found that plans overturned 75% of their own denials.

“The 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,” the report says. To make matters worse, enrollees and providers appeal only 1% of denials, the Inspector General found, suggesting that some beneficiaries may be going without needed services or paying out of pocket for care.

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And for patients, plan denials may have even broader repercussions. “If a provider is denied payment, they may be more reticent to provide certain services” in the future, says Leslie Fried, senior director at the National Council on Aging’s Center for Benefits Access.

Inappropriate denials are a growing concern as the number of Medicare Advantage plan beneficiaries soars. Advantage plans had 21 million enrollees in 2018, up from 8 million in 2007. As the government gives Advantage plans added flexibility, such as allowing them to offer supplemental benefits not covered by traditional Medicare, that number is likely to grow. But unlike traditional Medicare beneficiaries, Advantage plan enrollees looking to limit their costs must stay within their plan’s network of providers and typically need referrals to see specialists.

“Medicare Advantage plans are committed to providing quality, affordable and appropriate care to patients,” says Cathryn Donaldson, a spokesperson for America’s Health Insurance Plans, a health insurance industry group. A denial, she says, “can often be a request for additional information for the claim, or a move to an alternative treatment that’s more effective.”

Dealing With a Medicare Denial

It’s critical for Advantage plan beneficiaries to read their denial notices, understand their rights to appeal and file appeals promptly, patient advocates say.

But the denial notices that plans send to enrollees aren’t always clear, says Fred Riccardi, vice president of client services at the Medicare Rights Center. In 2015, audits by the Centers for Medicare and Medicaid Services found that 45% of Advantage plans sent denial letters with incomplete or incorrect information, according to the Inspector General’s report.

Follow the instructions on the denial notice to make your appeal. Ask your doctor to write a letter explaining why you need the care. And understand the timeline to make your claim. Advantage enrollees have only 60 days from the date of the denial notice to file an appeal with the plan, compared with 120 days for traditional Medicare beneficiaries. The plan must then make a decision within 30 days if it’s denying a service that you haven’t yet received, or 60 days if it’s refusing to pay for a service that you already received. If your health could be harmed by waiting for the standard appeals process to play out, request an expedited appeal, which requires a decision within 72 hours.

If the plan rejects your initial appeal, your claim will be automatically forwarded to an independent entity for review. And if your appeal is rejected there, you still have up to three more levels of appeal.

Helping Hands

The appeals process can be overwhelming, particularly for patients who are sick or frail. Find expert assistance through these resources:

State health insurance assistance programs. To find your local program, go to shiptacenter.org or call 877-839-2675.

Medicare Rights Center. An advocacy group for Medicare beneficiaries. Go to medicarerights.org or call 800-333-4114.

Legal aid programs. Find legal services in your area at eldercare.acl.gov or call 800-677-1116.