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Medicare Advantage Plan Care Denials

October 25, 2018

Medicare Advantage Insurers

on Notice

for Improper Care Denials

We buy insurance so that when we need it, it has our back.  One of the strongest arguments against choosing a Medicare Advantage Plan over Original Medicare is that with Advantage Plans you have to have approval for medical procedures.  Original Medicare’s intent is to cover everything that is medically necessary and they consult your doctor to help make that determination.  When you have a Medicare Advantage Plan it is the insurance company that makes the determination and they don’t consult your doctor.  If a Medicare Advantage Plan deems your procedure as not medically necessary, they won’t cover it and you cannot get the procedure unless you pay for it out of pocket.

Medicare Advantage Denial of ServiceNow, I know what you are thinking.  Your thinking that might impact some small procedures like a painful ingrown toenail, but major procedures are safe.  Right? Wrong!  Being in the business I hear horror stories of Care Denial all the time.  The TWO worst were cases where the patient needed an organ transplant.  (These were not my clients.  These are two people who called me for help and relayed their stories to me.) One needed a liver, the other a kidney.  The Advantage plan first refused to let one of them see a specialist. After a year of prodding, he was allowed to see a specialist who told him he needed a new kidney.  When he went back to his Primary Care physician he was told: “that’s not going to happen.”

The other needed a new liver.  The insurance company simply would not approve the procedure.  She called me for help.  I was able to point out that her particular insurance company was already under investigation for claims denials (see this article) and letting them know she will go to the press and the state insurance commissioner was the best course of action.  She was approved for a transplant a week later.

I am not the only one with these stories.  Now, the recent article in from Benefits Pro shows that Medicare is aware of these issues. 

From the article: “Federal auditors have found “widespread and persistent problems related to denials of care and payment in Medicare Advantage,” the privately administered plans that insure more than 20 million people, according to the report from the Health and Human Services Office of Inspector General.”   and “Improper denials “may contribute to physical harm for beneficiaries if they’re not getting access to services that they need,” said Rosemary Rawlins, the inspector general’s team leader on the report. Patients and doctors can also be harmed financially if not reimbursed for appropriate care, she said.”

Read the rest here:  



Private Medicare providers on notice for improper care denials


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