Medicare Advantage Plans Improperly Denying Claims

1. The Medicare Advantage (MA) program allows Medicare beneficiaries to receive benefits through private plans rather than the traditional fee-for-service (FFS) program. Aetna Medicare is a PDP, HMO, PPO plan with a Medicare contract. Medicare Advantage holds the promise of additional coverage for beneficiaries in a cost- controlled payment system achieved through collaboration with private insurers. 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. In 2015 alone, CMS found that more than half of the Medicare Advantage plans they audited (56 percent) inappropriately denied care or payment. If you have prescription drug coverage through a stand-alone Medicare Part D Prescription Drug Plan, file your appeal through your Medicare Part D Prescription Drug Plan. For information on how to obtain an aggregate number of grievances, appeals and exceptions filed with Sharp Health Plan or if you have a question about a status of an appeal, grievance or exception you requested, please call Customer Care at 1-855-562-8853 (TTY 711). Your second appeal or hearing must come within 60 days of being denied. If we approve a request for coverage, we will provide the coverage we have agreed to provide as quickly as the enrollee's health requires, but no later than seven calendar days after we receive the appeal. If Medicare will not pay for the services, the MSN should provide the reason why coverage is denied. The high volume of successful appeals, particularly on the first level, raises concerns that MAOs were denying payment and authorization for services that should have been provided, the OIG said. The findings reveal concerns about service and payment denial among Medicare Advantage, which covers more than 20 million Medicare beneficiaries in 2018. In some cases, the ALJ may decide to forgo a hearing How to Appeal Medicare Advantage Denial altogether and may decide the case on-the-record” when the evidence in the claim file supports a decision in your favor.