Medicare Advantage Organizations Overturn 75% of Their Denials 

By Kelly Gooch, Beckers Hospital Review. 

A recent investigation by the U.S. Office of Inspector General found between 2014 and 2016, Medicare Advantage organizations overturned 75 percent of their preauthorization and payment denials upon appeal.

The OIG’s report, released in September, found Medicare Advantage organizations overturned about 216,000 denials annually during the period. Investigators also found that independent reviewers overturned more denials at higher Medicare Advantage appeals levels.

“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 agency wrote. “This is especially concerning because beneficiaries and providers rarely used the appeals process, which is designed to ensure access to care and payment.  During 2014-16, beneficiaries and providers appealed only 1 percent of denials to the first level of appeal.”

In addition to the numbers of overturned denials, persistent performance problems related to Medicare Advantage organizations were identified by CMS audits, according to the OIG. Investigators said one example is CMS citing 56 percent of audited contracts for making inappropriate denials in 2015. They said 45 percent of contracts were also cited for providing incomplete or incorrect information in denial letters.

The OIG recommended CMS step up oversight of Medicare Advantage contracts, “including those with extremely high overturn rates and/or low appeal rates and take corrective action as appropriate” and offer beneficiaries easily accessible information about serious violations by Medicare Advantage organizations.

CMS agreed with the recommendations.

October 02, 2018