The Truth About Medicare Advantage Claim Denials and How You Can Appeal

Key Takeaways

• The fee of Medicare Advantage (MA) claims has escalated in recent times, prompting medical and authorities scrutiny of prior authorization processes that decelerate care in favor of price financial savings.
• However, you might have a very good likelihood of successful MA denial appeals and receiving acceptable protection for those who learn the principles, take motion, and supply sufficient documentation. 
• All through the declare enchantment course of, be persistent and keep factual communication that focuses on clear and complete info. 
• Make sure you meet the enchantment deadlines set by the insurance coverage firm or Medicare, and don’t be afraid to request sooner consideration for those who’re involved about your well being. 

When you’re a annoyed Medicare Advantage enrollee going through extra declare denials, you’re certainly one of thousands and thousands extra customers in the identical state of affairs. Happily, there are methods to take motion. 

A 2024 report from KFF discovered Medicare Advantage insurers absolutely or partially denied 7.4% (3.4 million) of claims submitted for well being care pre-authorization in 2022, a pointy soar up from 5.8% in 2021 and 5.6% in 2020. 

Medicare Advantage firms use prior authorization to decrease their claim-payment prices by managing how companies are used, usually requiring the method for sure companies, medical objects, inpatient care, or medicines. 

Sadly, delays within the prior authorization course of can result in adverse well being impacts. A 2024 American Medical Affiliation (AMA) survey discovered that 78% of physicians stated the prior authorization course of can generally result in sufferers abandoning the advisable therapy altogether.

The AMA, all 50 state medical associations, and quite a few healthcare establishments are expressing concern in regards to the climbing fee of MA denials. There’s additionally growing bipartisan Congressional scrutiny and assist for rushing up Medicare Advantage declare critiques, modernizing the method, and growing transparency in necessities. 

For instance, in November 2024, 135 Democrats and 86 Republicans co-sponsored laws to enhance the prior authorization course of. An identical Senate invoice had already drawn 54 co-sponsors from each events. 

Within the meantime, when your prior authorization or declare for previous service is denied, it might seem to be your solely choices are to pay out of pocket for the service or declare, work out an association with the supplier, or go with out the care. 

However, you may—and will—combat again towards denials. The odds are in your favor, too: KFF discovered that whereas solely about 10% of MA denials have been appealed in 2022, a staggering 83% of these appeals have been profitable, indicating they might have been initially denied in error. 

How to Contest a Medicare Advantage Claim Denial

1. Overview the Denial

Medicare Advantage plans are required to ship denials in writing, and denials are often defined as “not approved” or “not covered.” You additionally might obtain a verbal denial first, adopted by a written letter.    

Medicare Advantage plans often received’t require prior authorization for preventive care, however it’s possible you’ll want it—and you might be denied protection for:

• A selected service (equivalent to surgical procedure), provide, or medicine 
• A well being care service, provide, or medicine you’ve already obtained
• Persevering with a service or different care you’re receiving now
• Supplemental advantages supplied by your plan, not Medicare 

“The more expensive you become, the more opportunities the plan will have to require prior authorization or issue denials,” stated Tatiana Fassieux, training and coaching specialist for Medicare coverage, advocacy, and coaching at California Well being Advocates. 

For instance, Ozempic might solely be coated by your MA plan in case your want matches neatly inside FDA indications, equivalent to Kind 2 diabetes. However, your plan may impose different restrictions, too, like solely protecting Ozempic for one yr or solely protecting Ozempic after you’ve tried different medicines. 

A denial may also happen as a result of the medical biller didn’t add the suitable proof for the process. For instance, eye raise surgical procedure protection may require a surgeon's images of the attention. 

You may also need to begin an enchantment in case your Medicare Advantage plan modifications your pricing for a healthcare service, provide, or medicine. 

2. Overview Your Plan’s Appeal Rights 

Within the preliminary Medicare Advantage denial letter, your plan will inform you tips on how to enchantment. Usually, there are 5 ranges of appeals for an MA determination, often known as an "group dedication.”

“It’s a formal process,” Fassieux stated, and you could observe the steps described. “It’s important to follow through and not just accept the first denial.”

You can evaluate your Medicare Advantage plan's particular enchantment rights and guidelines within the “Evidence of Coverage” in your insurer’s web site, usually as a PDF. Additionally pay attention to the timelines for every step of the enchantment course of. There may be steerage on how greatest to enchantment, notably for prior authorizations that must occur shortly. 

If time is of the essence for well being and security causes, your insurer may state a “fast appeal” usually occurs by a cellphone name or in writing. Extra commonplace timeline appeals are made in writing. 

Medicare Half D denials might require totally different paperwork and processes, so evaluate your plan’s documentation. You can generally request an “exception” for medicine protection. 

Appeal Stage 1: Reconsideration From Your Plan

Stage 1 appeals are referred to as “Health Plan Reconsiderations” by your plan supplier. 

When you file an enchantment, the plan will inform you of its determination inside 30 days for those who requested a service and 60 days for those who requested a cost. 

If the plan doesn’t determine in your favor or doesn’t reply, your enchantment mechanically forwards to Stage 2, which entails a company exterior your insurance coverage firm. 

You can get a sooner reconsideration if the 30- or 60-day timeframe jeopardizes your well being.

You may request a direct determination evaluate for those who obtain companies in some amenities, equivalent to an inpatient hospital admission (usually coated underneath Medicare Half A) or expert nursing facility, and the plan decides to discharge you.  

Appeal Stage 2: Impartial Overview Entity (IRE)

At this stage, your enchantment is mechanically despatched to an out of doors group for evaluate. The enchantment course of timeline is dependent upon which service was concerned:

• Preauthorization enchantment: 30 days
• Fee enchantment: 60 days
• Half B medication: 7 days
• Quick enchantment: 72 hours

In some circumstances, your plan can prolong the appeals deadline by 14 days if it gives notification and cause, equivalent to needing extra info to determine. You’ll additionally be told relating to your rights for those who disagree with the extension determination. 

If the Impartial Overview Entity thinks your life or well being is in danger resulting from ready, you’ll fall underneath “fast appeal.” 

If the skin group additionally denies your enchantment, you might have 60 days from the choice date to ask for a Stage 3 enchantment.

You can learn Half C and Half D enchantment outcomes on the Facilities for Medicare & Medicaid Providers (CMS) website to know how choices are made. 

Appeal Ranges 3 to five 

When you disagree with the Stage 2 determination, you may enchantment at increased ranges, however the greenback quantity in rivalry will dictate how far your enchantment can go. Your plan can enchantment the end result as properly.

3. Craft Your Claim Denial Appeal

When it comes time to craft your enchantment, you’ll usually work along with your physician. Appeal paperwork is on the market by your Medicare Advantage insurance coverage firm and can seemingly embody requests for the next: 

• Your private info 
• Your description of the problem
• Medical historical past and therapy suggestions 
• Outcomes you hope to get from the insurance coverage firm

You may need to embody particulars about your: 

• Medical historical past
• Diagnostic check outcomes
• Specialist suggestions
• Remedy plans
• Detailed medical notes 

It’s additionally advisable you present an evidence in regards to the medical necessity of what you want or have already obtained and paid for. Be prepared to barter with numerous entities to discover a decision that works.

Hold detailed information of all communications, together with notes on the date, time, who you spoke with, and what was stated. 

When you want extra assist along with your enchantment, contact a facility or medical follow’s affected person advocate or your State Well being Insurance coverage Help Program (SHIP). You may appoint a buddy, member of the family, doctor, or lawyer as a consultant as you enchantment choices. 

One other Choice: Select a New Plan 

When you really feel your plan places you in too many troublesome positions relating to denials, make the most of the annual January 1-March 31 Medicare Advantage open enrollment interval. 

Overview the “Evidence of Coverage” when contemplating a Medicare Advantage plan to guage the language used round appeals. Analysis plans to find out which companies and medicines might require prior authorization in 2025. Communicate along with your native State Well being Insurance coverage Help Program (SHIP) for extra recommendation. 

Additionally, be skeptical of promoting that advertises cheap generic-tier medicines—they received't do you a lot good in case your medicine isn’t coated or you must bear a posh course of to get it. 

Fassieux prompt that with Medicare Advantage and Half D, look previous the zero-premium advertising and most out-of-pocket quantities. As an alternative, evaluate all plan components.  

“We’re entering a time now in healthcare where the right coverage isn’t a given,” Fassieux stated. “Think about it, and be careful and judicious in your plan choice.”  

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