Appeals for payment denials were overturned 75 percent of the time by Medicare Advantage Organizations from 2014 to 2016, according to HHS Office of Inspector General.
The percentage represents approximately 216,000 denials each year, appealed by beneficiaries and providers to MAOs, the OIG found in a review of payments. The findings reveal concerns about service and payment denial among Medicare Advantage, which covers more than 20 million Medicare beneficiaries in 2018. Further up the chain of appeals, independent reviewers overturned more denials in favor of beneficiaries and providers.
“High numbers of overturned denials upon appeal, and persistent performance problems identified by CMS audits, raise concerns that some beneficiaries and providers may not be getting services and payment that MAOs are required to provide,” the report reads.
Appeals only represented 1 percent of denials to the first level of appeal during the 2014-2016 period.
CMS audits have also highlighted widespread and persistent performance problems with MAOs related to denials of care and payment, OIG states. In 2016, CMS cited 56 percent of audited contracts for making inappropriate denials and 45 percent of contracts for sending denial letters with incomplete or incorrect information, which can make the appeals process difficult for beneficiaries and providers. CMS issued penalties and sanctions, but more action is needed, the agency stated.
To improve the denials rate and ensure compliance with respect to payments and services by MAOs, OIG recommends that CMS implement stronger oversight of MAO contracts–particularly those with extremely high turnover rates and/or low appeal rates. CMS should also address persistent problems with inappropriate denials and insufficient denial letters and provide beneficiaries with information about violations by MAOs.
Amy joined TriMed Media as a Senior Writer for HealthExec after covering home care for three years. When not writing about all things healthcare, she fulfills her lifelong dream of becoming a pirate by sailing in regattas and enjoying rum. Fun fact: she sailed 333 miles across Lake Michigan in the Chicago Yacht Club "Race to Mackinac."