Medicare enrollment begins on October 15. During this time Medicare enrollees can switch from original Medicare to a Medicare Advantage plan. Or, if already enrolled in an Advantage plan, change to a different one. However, Be Aware When Choosing a Medicare Advantage Plan.
If you are considering a Medicare Advantage, understand that there is a growing concern that these plans frequently deny claims and thus limit access to health care.
Be Aware When Choosing a Medicare Advantage Plan
Concerns about Medicare Advantage plans are highlighted in a report released in April 2022. This was done by the inspector general’s office of the United States Department of Health and Human Services (HHS). The report says, while Medicare Advantage plans “approve the vast majority of requests for service and payment,” annual audits of these plans “have highlighted widespread and persistent problems related to inappropriate denials of services and claims.”
More and more people are choosing Medicare Advantage plans. These plans often have low or no premiums. They also offer extra benefits that original Medicare does not provide. Whereas original Medicare is administrated by the federal government, Medicare Advantage plans are provided by Medicare-approved private for-profit companies. They advertise heavily on TV and via direct mail. The open enrollment period from October 15th through December 7th.
Medicare Advantage Plan Concerns
The HHS report states these plans “sometimes delayed or denied Medicare Advantage beneficiaries’ access to services even though the requests met Medicare coverage rules.” Of the prior authorization requests denied, 13 percent “likely would have been approved for these beneficiaries under original Medicare.”
The result of these denials may have prevented or delayed patients from receiving medically necessary care. Delays in care and having to receive prior approvals can lead to adverse events for patients. These include hospitalization, medical intervention, disability, or death.
Audit Results
The HHS audits also found 18% of the payments that were denied to providers met both Medicare coverage rules and the plans’ own billing rules. These denials are attributed to both “human error during manual claims review and system processing errors.“ Denied payments create an administrative burden for providers.
The HHS report says, “Although some of the denials that we reviewed were ultimately reversed by the (plan), avoidable delays and extra steps create friction in the program and may create an administrative burden for beneficiaries, providers and the (plan.” In other words, to get coverage for medical services that should not have been denied in the first place, patients enrolled in these plans and their providers had to go through an appeals process.
Do Your Research
If you find a Medicare Advantage plan you think is good for you, do your research before signing up. Don’t be swayed by advertising alone. When considering a Medicare Advantage plan, BoomerBenefits.com offers advice. You can also read my blog Medicare Advantage: Make Sure It’s the Right Plan For You.
I recently attended a continuing education webinar on Medicare. I asked the presenter about Medicare Advantage plans denying medically necessary services. He said unfortunately it happens across all plans. He said beneficiaries enrolled in Medicare Advantage need to know their rights and benefits and be prepared to file an appeal.
This blog is published to provide you with general information only, and is not intended to provide specific or comprehensive advice. Money Care, LLC encourages individuals to seek advice from competent professionals when appropriate.
