Medicare Advantage denials

Health care service denials are a recurring problem in Florida

Every year, a lot of people are receiving Medicare Advantage denials for health care services. However, many of these service requests should be covered under the Advantage programs in Florida. Plus, this is also happening all over the country, according to the federal investigators in a report published in April 2022.

The total number of Americans enrolled in Advantage plans has increased over the last decade. And, half of Medicare beneficiaries are expected to choose a Medicare Advantage insurer in the next couple of years.

Medicare Advantage plans are a popular option among Americans. These services offer privatized versions of Medicare. And, Advantage plans frequently deliver great services, wider access to care, and better prices than the government offers.

However, federal investigators claim that there is evidence that some of these plans are delaying Medicare beneficiaries from getting their necessary care.

Payment model problems

An Office of the Inspector General (OIG) study was published due to a concern with the payment model used in Medicare Advantage. It found that this payment model may provide a potential incentive for healthcare organizations to deny a member access to services in an effort to increase its profits.

They (OIG) know that Medicare Advantage Organizations approve most requests for services, but they also have found that they deny millions of requests each year. In addition, annual audits by the Medicare Center of Services have highlighted widespread and persistent payment problems. All related to inappropriate denials of service.

Beneficiaries denied access to healthcare

Further, the report also says that some beneficiaries are denied access to services that meet the coverage rules. As a result, denied requests that should have been approved pushed beneficiaries away from receiving necessary care.

Tens of millions of denials are issued each year for authorizations. Also, the audits of the private insurers show evidence of persistent problems related to inappropriate denials of services.

And later on, some of the denials that were reviewed were reversed by the organizations. But avoidable delays and extra steps created difficulties and exhaustion in those who needed treatment. Examples of health care services involved in denials that met Medicare coverage rules included: advanced imaging services and post-acute facility stays for inpatient rehabilitation.

What will be done to the Medicare Advantage Organization that denies requests?

The investigators appealed to Medicare officials to keep monitoring private insurance plans and called for increased punishment against plans with a pattern of compulsive denials.

These denials can delay or avoid a Medicare Advantage beneficiary from getting needed care.

Medicare officials also published a statement saying that they are reviewing the reports to determine the next steps to resolve the problem. And, Medicare Advantage organizations that have repeated denial violations may be subject to increasing penalties.

The study found that Medicare Advantage Organizations reversed some of the denied authorizations that met Medicare coverage. Plus, Medicare Advantage Organizations reversed some of their rules when a beneficiary appealed or disputed the denial. In some cases, Medicare Advantage Organizations identified their own errors.

So, what should you do if you have been denied access to health care services through your Medicare Advantage Plan?

1. One of the first things to do if you have been denied a healthcare service is to appeal these decisions with your specific insurer.
2. To ensure that you have timely access to all necessary healthcare services, call your health insurance expert agent as soon as you receive a denial.
3. If you are in a Medicare Advantage plan and had your care denied, you can appeal to Medicare about the plan’s decision to not allow, not pay for, or stop a health care service that you think should be provided.
4. Lastly, when working side by side with your Florida Health Agency expert, they will help and guide you through the process of appealing the decision. They will also consult your plan materials for detailed information, and explain everything you need to know to proceed.