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IG Report on Medicare Advantage Denial of Service

October 27, 2018


This is a second blog post on what I believe to be THE most important issue for people on Medicare.  Whether you are new to Medicare or have has Medicare for years this is important information if you ever decide to consider a Medicare Advantage plan.

You can find my first Blog post on this subject here: Medicare Advantage Insurers on Notice for Improper Care Denials

So, how can we build on that post?  Linked below is a brief report by the US Office of Inspector General for the U.S. Department of Health & Human Services.  This is CMS’s (Center for Medicare & Medicaid Services) Inspector General.  CMS runs Medicare and Medicaid.

Medicare Advantage Denial of ServiceThis report is of a study the Inspector General did that ran from 2014-2016.  In brief, the report found that each year more than half of all Medicare Advantage plans were denying Services or payment for procedures that are medically necessary and should have been performed.  While the majority of the denials that were appealed were approved as a result of the appeal, the report found that only 1% of the beneficiaries that were denied service even attempted to appeal the process.  This is huge.  This means that people are harmed by not receiving the medical treatment they need, deserve and expect from their Medicare insurance. 

 

In addition, the Inspector General found that insurance companies were denying payment of approved services after the fact. In other words, the beneficiary would get the medical procedure they needed, but after it was complete the insurance company would deny payment, putting both the health care provider and the beneficiary in a bad spot financially.

“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.”   IG report dated September 2018

The reason any of us get health insurance is so that 1. when we need medical treatment we know it will be available to us and 2. a medical event does not become a financial event.  It’s difficult enough dealing with health issues when everything goes right.  To have to battle an insurance company for necessary medical treatment or for payment of medically necessary treatment s appalling.

This is the prime reason why I and my company recommend keeping your Original Medicare A & B and adding a Medicare supplement.  Although your Medicare supplement is offered by a private insurance company. All the Medicare supplement can do is what Medicare instructs them to do.  A Medicare supplement has no say in what is covered or what is paid.  Medicare calls the shots.

With a Medicare supplement, you can see any doctor or go to any medical facility in the US or its territories and receive full coverage.  You do not have to ask permission for a medical procedure your doctor deems is medically necessary.  And Medicare is not going to deny you treatment, coverage or payment for profit.  

“Centers for Medicare & Medicaid Services (CMS) audits highlight widespread
and persistent MAO performance problems related to denials of care and
payment. For example, in 2015, CMS cited 56 percent of audited contracts for
making inappropriate denials. CMS also cited 45 percent of contracts for
sending denial letters with incomplete or incorrect information, which may
inhibit beneficiaries’ and providers’ ability to file a successful appeal.” IG report dated September 2018

Medigap Seminars has the personnel and expertise to help our clients through the Medicare Appeals process.


Medicare Questions Call UsOne thing I tell each and every client after we have helped them with their Medicare supplement is that if you ever have a problem.  If you are denied coverage you believe is medically necessary, if you have a denied payment or incorrect doctor bill, don’t bang your head against the wall trying to resolve these issues on your own.  That’s our job!  We help all our client through this process.  I have on staff people with associates degrees in Medical billing who have been Medicare Analysts or who have managed billing departments for major medical facilities.  WE CAN HELP and we love doing it.   In the past two weeks alone we helped a client reverse an unpaid claim for $3,400 to just $19.  We helped another who needed a particular medical test that was denied, appeal and get the test approved.  When you become a client of Medigap Seminars Insurance Agency you can rest assured we have your back!  

Please complete the quote request below if you would like more information on the Medicare supplement plans in your area.

You can read the Inspector General full report here:

U.S. Department of Health and Human Services
Office of Inspector General Report on Medicare Advantage Plans

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