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

Investopedia2024-12-17

Key Takeaways The rate of Medicare Advantage (MA) claims has escalated in recent years, prompting medical and government scrutiny of prior authorization processes that slow down care in favor of cost ...

Source Link

Disclaimer: Investing carries risk. This is not financial advice. The above content should not be regarded as an offer, recommendation, or solicitation on acquiring or disposing of any financial products, any associated discussions, comments, or posts by author or other users should not be considered as such either. It is solely for general information purpose only, which does not consider your own investment objectives, financial situations or needs. TTM assumes no responsibility or warranty for the accuracy and completeness of the information, investors should do their own research and may seek professional advice before investing.

Comments

We need your insight to fill this gap

Leave a comment

{"i18n":{"language":"en_US"},"isChannel":false,"data":{"share":"https://ttm.financial/m/news/2492958931?lang=en_US&edition=fundamental","thumbnail":"https://www.investopedia.com/thmb/cYrs3DeiQK46lLzjporpxutcolc=/7346x4900/filters:no_upscale():max_bytes(150000):strip_icc()/GettyImages-1386035259-5b1630cdca034fe59e58d213734af59d.jpg","is_english":true,"pubTime":"2024-12-17 19:00","share_image_url":"https://static.laohu8.com/e9f99090a1c2ed51c021029395664489","id":"2492958931","market":"sg","top_or_hot":-1,"title":"The Truth About Medicare Advantage Claim Denials and How You Can Appeal","media":"Investopedia","content":"<div>\n<p>Key Takeaways\nThe rate of Medicare Advantage (MA) claims has escalated in recent years, prompting medical and government scrutiny of prior authorization processes that slow down care in favor of cost ...</p>\n\n<a href=\"https://www.investopedia.com/the-truth-about-medicare-advantage-claim-denials-and-how-you-can-appeal-8762198\">Source Link</a>\n\n</div>\n","source":"investopedia_highlight","html":"<!DOCTYPE html>\n<html>\n<head>\n<meta http-equiv=\"Content-Type\" content=\"text/html; charset=utf-8\" />\n<meta name=\"viewport\" content=\"width=device-width,initial-scale=1.0,minimum-scale=1.0,maximum-scale=1.0,user-scalable=no\"/>\n<meta name=\"format-detection\" content=\"telephone=no,email=no,address=no\" />\n<title>The Truth About Medicare Advantage Claim Denials and How You Can Appeal</title>\n<style type=\"text/css\">\na,abbr,acronym,address,applet,article,aside,audio,b,big,blockquote,body,canvas,caption,center,cite,code,dd,del,details,dfn,div,dl,dt,\nem,embed,fieldset,figcaption,figure,footer,form,h1,h2,h3,h4,h5,h6,header,hgroup,html,i,iframe,img,ins,kbd,label,legend,li,mark,menu,nav,\nobject,ol,output,p,pre,q,ruby,s,samp,section,small,span,strike,strong,sub,summary,sup,table,tbody,td,tfoot,th,thead,time,tr,tt,u,ul,var,video{ font:inherit;margin:0;padding:0;vertical-align:baseline;border:0 }\nbody{ font-size:16px; line-height:1.5; color:#999; background:transparent; }\n.wrapper{ overflow:hidden;word-break:break-all;padding:10px; }\nh1,h2{ font-weight:normal; line-height:1.35; margin-bottom:.6em; }\nh3,h4,h5,h6{ line-height:1.35; margin-bottom:1em; }\nh1{ font-size:24px; }\nh2{ font-size:20px; }\nh3{ font-size:18px; }\nh4{ font-size:16px; }\nh5{ font-size:14px; }\nh6{ font-size:12px; }\np,ul,ol,blockquote,dl,table{ margin:1.2em 0; }\nul,ol{ margin-left:2em; }\nul{ list-style:disc; }\nol{ list-style:decimal; }\nli,li p{ margin:10px 0;}\nimg{ max-width:100%;display:block;margin:0 auto 1em; }\nblockquote{ color:#B5B2B1; border-left:3px solid #aaa; padding:1em; }\nstrong,b{font-weight:bold;}\nem,i{font-style:italic;}\ntable{ width:100%;border-collapse:collapse;border-spacing:1px;margin:1em 0;font-size:.9em; }\nth,td{ padding:5px;text-align:left;border:1px solid #aaa; }\nth{ font-weight:bold;background:#5d5d5d; }\n.symbol-link{font-weight:bold;}\n/* header{ border-bottom:1px solid #494756; } */\n.title{ margin:0 0 8px;line-height:1.3;color:#ddd; }\n.meta {color:#5e5c6d;font-size:13px;margin:0 0 .5em; }\na{text-decoration:none; color:#2a4b87;}\n.meta .head { display: inline-block; overflow: hidden}\n.head .h-thumb { width: 30px; height: 30px; margin: 0; padding: 0; border-radius: 50%; float: left;}\n.head .h-content { margin: 0; padding: 0 0 0 9px; float: left;}\n.head .h-name {font-size: 13px; color: #eee; margin: 0;}\n.head .h-time {font-size: 11px; color: #7E829C; margin: 0;line-height: 11px;}\n.small {font-size: 12.5px; display: inline-block; transform: scale(0.9); -webkit-transform: scale(0.9); transform-origin: left; -webkit-transform-origin: left;}\n.smaller {font-size: 12.5px; display: inline-block; transform: scale(0.8); -webkit-transform: scale(0.8); transform-origin: left; -webkit-transform-origin: left;}\n.bt-text {font-size: 12px;margin: 1.5em 0 0 0}\n.bt-text p {margin: 0}\n</style>\n</head>\n<body>\n<div class=\"wrapper\">\n<header>\n<h2 class=\"title\">\nThe Truth About Medicare Advantage Claim Denials and How You Can Appeal\n</h2>\n\n<h4 class=\"meta\">\n\n\n2024-12-17 19:00 GMT+8&nbsp;&nbsp;&nbsp;<a href=https://www.investopedia.com/the-truth-about-medicare-advantage-claim-denials-and-how-you-can-appeal-8762198><strong>Investopedia</strong></a>\n\n\n</h4>\n\n</header>\n<article>\n<div>\n<p>Key Takeaways\nThe rate of Medicare Advantage (MA) claims has escalated in recent years, prompting medical and government scrutiny of prior authorization processes that slow down care in favor of cost ...</p>\n\n<a href=\"https://www.investopedia.com/the-truth-about-medicare-advantage-claim-denials-and-how-you-can-appeal-8762198\">Source Link</a>\n\n</div>\n\n\n</article>\n</div>\n</body>\n</html>\n","isBrief":false,"type":0,"news_type":1,"symbol":"LU2092627202.USD","symbol_name":"Blackrock ESG Multi-Asset A8 USD-H","start_time":0,"source_url":"https://www.investopedia.com/the-truth-about-medicare-advantage-claim-denials-and-how-you-can-appeal-8762198","article_id":"2492958931","we_media_id":null,"thumbnails":["https://www.investopedia.com/thmb/cYrs3DeiQK46lLzjporpxutcolc=/7346x4900/filters:no_upscale():max_bytes(150000):strip_icc()/GettyImages-1386035259-5b1630cdca034fe59e58d213734af59d.jpg"],"rights":null,"url":"https://stock-news.laohu8.com/highlight/detail?id=2492958931","pubTimestamp":1734433200,"columns":[],"sourceInfo":{"source_id":"investopedia_highlight","name":"Investopedia"},"weMediaInfo":null,"summary":"If you’re a frustrated Medicare Advantage enrollee facing more claim denials, you’re one of millions more consumers in the same situation. Fortunately, there are ways to take action.A 2024 report from KFF found Medicare Advantage insurers fully or partially denied 7.4%  of claims submitted for health care pre-authorization in 2022, a sharp jump up from 5.8% in 2021 and 5.6% in 2020.Medicare Advantage companies use prior authorization to lower their claim-payment costs by managing how services are used, often requiring the process for certain services, medical items, inpatient care, or medications.Unfortunately, delays in the prior authorization process can lead to negative health impacts. A 2024 American Medical Association  survey found that 78% of physicians said the prior authorization process can sometimes lead to patients abandoning the recommended treatment altogether.Medicare Advantage plans are required to send denials in writing, and denials are usually explained as “not appro","collect":0,"end_time":0,"defaultTopTitle":"investopedia.com","property":[],"viewcount":null,"language":"en","relate_stocks":{"LU2092627202.USD":"Blackrock ESG Multi-Asset A8 USD-H","LU1894683264.USD":"AMUNDI FUNDS US EQUITY RESEARCH VALUE \"A2\" (USD) ACC","SHIP":"Seanergy Maritime Holdings Corp","LU0320765059.SGD":"FTIF - Franklin US Opportunities A Acc SGD","LU0011850046.USD":"贝莱德全球长线股票 A2 USD","LU1803068979.SGD":"FTIF - Franklin Technology A (acc) SGD-H1","IE00BQXX3C00.GBP":"GUINNESS GLOBAL INNOVATORS \"C\" (GBP) ACC","LU0642271901.SGD":"Janus Henderson Horizon Global Technology Leaders A2 SGD-H","LU0198837287.USD":"UBS (LUX) EQUITY SICAV - USA GROWTH \"P\" (USD) ACC","LU0672654240.SGD":"FTIF - Franklin US Opportunities A Acc SGD-H1","LU0316494557.USD":"FRANKLIN GLOBAL FUNDAMENTAL STRATEGIES \"A\" ACC","LU0345769128.USD":"NINETY ONE GSF GLOBAL EQUITY \"A\" (USD) ACC","IE00BQXX3F31.USD":"GUINNESS GLOBAL INNOVATORS \"C\" (USD) ACC","CMS":"CMS能源","LU2552382215.SGD":"WELLINGTON US BRAND POWER \"A\" (SGDHDG) ACC","LU0971096721.USD":"富达环球金融服务 A","SGXZ99366536.SGD":"United Global Innovation A Acc SGD-H","LU1718418525.SGD":"JPMorgan Investment Funds - Global Select Equity A (acc) SGD","LU0786609619.USD":"高盛全球千禧一代股票组合Acc","LU2552382058.USD":"WELLINGTON US BRAND POWER \"A\" (USD) ACC","IRE.AU":"IRESS LTD","LU1551013425.SGD":"Allianz Income and Growth Cl AMg2 DIS H2-SGD","LU1316542783.SGD":"Janus Henderson Horizon Global Technology Leaders A2 SGD","BK4585":"ETF&股票定投概念","LU0345769631.USD":"NINETY ONE GSF GLOBAL EQUITY \"A\" (USD) INC","BK4227":"交易和支付处理服务","AMA.AU":"AMA GROUP LTD","MA":"万事达","LU1629891620.HKD":"ALLIANZ INCOME AND GROWTH \"AMG2\" (H2-HKD) INC","BK4566":"资本集团","LU1917777945.USD":"安联专题基金Cl AT Acc","LU0957791311.USD":"THREADNEEDLE (LUX) GLOBAL FOCUS \"ZU\" (USD) ACC","LU2346227817.USD":"BGF SUSTAINABLE GLOBAL INFRASTRUCTURE \"A2\" (USD) ACC","LU1974910355.USD":"Allianz Thematica Cl AMg DIS USD","LU0109391861.USD":"富兰克林美国机遇基金A Acc","LU2764263039.SGD":"BGF GLOBAL UNCONSTRAINED EQUITY \"A2\" (SGDHDG) ACC","BK4527":"明星科技股","LU0170899867.USD":"EASTSPRING INVESTMENTS WORLD VALUE EQUITY  \"A\" (USD) ACC","LU2108987350.USD":"UBS (LUX) EQUITY SICAV GLOBAL OPPORTUNITY SUSTAINABLE (USD) \"P\" (USD) ACC","LU1670628061.USD":"M&G (LUX) NORTH AMERICAN DIVIDEND \"A\" (USD) INC","BK4588":"碎股","LU2461242641.AUD":"WELLINGTON US QUALITY GROWTH \"A\" (AUDHDG) ACC","LU0056508442.USD":"贝莱德世界科技基金A2","BK4208":"复合型公用事业","LU1153585028.USD":"BGF GLOBAL LONG-HORIZON EQUITY  \"A4\" (USD) INC","LU0107464264.USD":"abrdn SICAV I - GLOBAL INNOVATION EQUITY \"A\" (USD) ACC","LU1712237335.SGD":"Natixis Mirova Global Sustainable Equity H-R-NPF/A SGD","LU1280957306.USD":"THREADNEEDLE (LUX) US CONTRARIAN CORE EQUITIES \"AUP\" (USD) INC","LU1261432733.SGD":"Fidelity World A-ACC-SGD","LU0234572021.USD":"高盛美国核心股票组合Acc"},"translate_title":"Medicare Advantage索赔被拒绝的真相以及如何上诉","themeId":null,"isJumpTheme":false,"ttsUrl":null,"symbols_score_info":{"SHIP":1,"MA":1,"AMA.AU":1,"CMS":1,"IRE.AU":1},"content_text":"Key Takeaways\nThe rate of Medicare Advantage (MA) claims has escalated in recent years, prompting medical and government scrutiny of prior authorization processes that slow down care in favor of cost savings.However, you have a good chance of winning MA denial appeals and receiving appropriate coverage if you read the rules, take action, and provide adequate documentation. Throughout the claim appeal process, be persistent and maintain factual communication that focuses on clear and comprehensive information. Ensure you meet the appeal deadlines set by the insurance company or Medicare, and don’t be afraid to request faster consideration if you’re concerned about your health. \n If you’re a frustrated Medicare Advantage enrollee facing more claim denials, you’re one of millions more consumers in the same situation. Fortunately, there are ways to take action. \n\n\n A 2024 report from KFF found Medicare Advantage insurers fully or partially denied 7.4% (3.4 million) of claims submitted for health care pre-authorization in 2022, a sharp jump up from 5.8% in 2021 and 5.6% in 2020. \n\n\n Medicare Advantage companies use prior authorization to lower their claim-payment costs by managing how services are used, often requiring the process for certain services, medical items, inpatient care, or medications. \n\n\n Unfortunately, delays in the prior authorization process can lead to negative health impacts. A 2024 American Medical Association (AMA) survey found that 78% of physicians said the prior authorization process can sometimes lead to patients abandoning the recommended treatment altogether.\n\n\n The AMA, all 50 state medical associations, and numerous healthcare institutions are expressing concern about the climbing rate of MA denials. There’s also increasing bipartisan Congressional scrutiny and support for speeding up Medicare Advantage claim reviews, modernizing the process, and increasing transparency in requirements. \n\n\n For example, in November 2024, 135 Democrats and 86 Republicans co-sponsored legislation to improve the prior authorization process. A similar Senate bill had already drawn 54 co-sponsors from both parties. \n\n\n In the meantime, when your prior authorization or claim for past service is denied, it may seem like your only options are to pay out of pocket for the service or claim, work out an arrangement with the provider, or go without the care. \n\n\n However, you can—and should—fight back against denials. The odds are in your favor, too: KFF found that while only about 10% of MA denials were appealed in 2022, a staggering 83% of those appeals were successful, indicating they may have been initially denied in error. \n\n\n  How to Contest a Medicare Advantage Claim Denial  \n  1. Review the Denial  \n Medicare Advantage plans are required to send denials in writing, and denials are usually explained as “not approved” or “not covered.” You also may receive a verbal denial first, followed by a written letter.    \n\n\n Medicare Advantage plans usually won’t require prior authorization for preventive care, but you may need it—and you could be denied coverage for:\n\n\n A specific service (such as surgery), supply, or medication A health care service, supply, or medication you’ve already receivedContinuing a service or other care you’re receiving nowSupplemental benefits provided by your plan, not Medicare \n\n\n “The more expensive you become, the more opportunities the plan will have to require prior authorization or issue denials,” said Tatiana Fassieux, education and training specialist for Medicare policy, advocacy, and training at California Health Advocates. \n\n\n For example, Ozempic may only be covered by your MA plan if your need fits neatly within FDA indications, such as Type 2 diabetes. However, your plan might impose other restrictions, too, like only covering Ozempic for one year or only covering Ozempic after you’ve tried other medications. \n\n\n A denial might also occur because the medical biller didn’t add the right evidence for the procedure. For example, eye lift surgery coverage might require a surgeon's photos of the eye. \n\n\n\nYou might also want to start an appeal if your Medicare Advantage plan changes your pricing for a healthcare service, supply, or medication. \n  2. Review Your Plan’s Appeal Rights   \n In the initial Medicare Advantage denial letter, your plan will tell you how to appeal. In general, there are five levels of appeals for an MA decision, also known as an \"organization determination.”\n\n\n “It’s a formal process,” Fassieux said, and you need to follow the steps described. “It’s important to follow through and not just accept the first denial.”\n\n\n You can review your Medicare Advantage plan's specific appeal rights and rules in the “Evidence of Coverage” on your insurer’s website, typically as a PDF. Also take note of the timelines for each step of the appeal process. There may also be guidance on how best to appeal, particularly for prior authorizations that need to happen quickly. \n\n\n If time is of the essence for health and safety reasons, your insurer might state a “fast appeal” typically happens through a phone call or in writing. More standard timeline appeals are made in writing. \n\n\n\nMedicare Part D denials may require different paperwork and processes, so review your plan’s documentation. You can sometimes request an “exception” for medication coverage. \n  Appeal Level 1: Reconsideration From Your Plan  \n Level 1 appeals are called “Health Plan Reconsiderations” by your plan provider. \n\n\n If you file an appeal, the plan will inform you of its decision within 30 days if you requested a service and 60 days if you requested a payment. \n\n\n If the plan doesn’t decide in your favor or doesn’t respond, your appeal automatically forwards to Level 2, which involves an organization outside your insurance company. \n\n\n\nYou can get a faster reconsideration if the 30- or 60-day timeframe jeopardizes your health.\n You can also request an immediate decision review if you receive services in some facilities, such as an inpatient hospital admission (typically covered under Medicare Part A) or skilled nursing facility, and the plan decides to discharge you.  \n\n\n  Appeal Level 2: Independent Review Entity (IRE)  \n At this level, your appeal is automatically sent to an outside organization for review. The appeal process timeline depends on which service was involved:\n\n\n Preauthorization appeal: 30 daysPayment appeal: 60 daysPart B drugs: 7 daysFast appeal: 72 hours\n\n\n In some cases, your plan can extend the appeals deadline by 14 days if it provides notification and reason, such as needing more information to decide. You’ll also be informed regarding your rights if you disagree with the extension decision. \n\n\n If the Independent Review Entity thinks your life or health is at risk due to waiting, you’ll fall under “fast appeal.” \n\n\n If the outside organization also denies your appeal, you have 60 days from the decision date to ask for a Level 3 appeal.\n\n\n\nYou can read Part C and Part D appeal outcomes on the Centers for Medicare & Medicaid Services (CMS) site to understand how decisions are made. \n  Appeal Levels 3 to 5   \n If you disagree with the Level 2 decision, you can appeal at higher levels, but the dollar amount in contention will dictate how far your appeal can go. Your plan can appeal the outcome as well.\n\n\n \n\n\n\n\n\n\n\n \nLevel 3\nLevel 4\nLevel 5\n\n\n\n\nAmount of Money In Controversy (2025)\n $190 or more\nNo minimum \n$1,900 or more \n\n\nWho Reviews Your Appeal\nAdministrative law judge or federal government attorney adjudicator\nThe federal Medicare Appeals Council\nA federal district court judge\n\n\nWho Can Appeal\nYou or your MA plan \nYou or your MA plan\nNo more appeals are possible after Level 5\n\n\n\n\n  3. Craft Your Claim Denial Appeal  \n When it comes time to craft your appeal, you’ll typically work with your doctor. Appeal paperwork is available through your Medicare Advantage insurance company and will likely include requests for the following: \n\n\n Your personal information Your description of the issueMedical history and treatment recommendations Results you hope to get from the insurance company\n\n\n You may also want to include details about your: \n\n\n Medical historyDiagnostic test resultsSpecialist recommendationsTreatment plansDetailed clinical notes \n\n\n It’s also recommended you provide an explanation about the medical necessity of what you need or have already received and paid for. Be ready to negotiate with various entities to find a resolution that works.\n\n\n Keep detailed records of all communications, including notes on the date, time, who you spoke with, and what was said. \n\n\n\nIf you need additional help with your appeal, contact a facility or medical practice’s patient advocate or your State Health Insurance Assistance Program (SHIP). You can also appoint a friend, family member, physician, or lawyer as a representative as you appeal decisions. \n  Another Option: Choose a New Plan   \n If you feel your plan puts you in too many difficult positions regarding denials, take advantage of the annual January 1-March 31 Medicare Advantage open enrollment period. \n\n\n Review the “Evidence of Coverage” when considering a Medicare Advantage plan to judge the language used around appeals. Research plans to determine which services and medications could require prior authorization in 2025. Speak with your local State Health Insurance Assistance Program (SHIP) for more advice. \n\n\n Also, be skeptical of marketing that advertises inexpensive generic-tier medications—they won't do you much good if your medication isn’t covered or you have to undergo a complex process to get it. \n\n\n Fassieux suggested that with Medicare Advantage and Part D, look past the zero-premium marketing and maximum out-of-pocket amounts. Instead, review all plan elements.  \n\n\n “We’re entering a time now in healthcare where the right coverage isn’t a given,” Fassieux said. “Think about it, and be careful and judicious in your plan choice.”  \n\nDo you have a news tip for Investopedia reporters? Please email us at\ntips@investopedia.com","kind":"highlight","is_publish_news":true,"is_publish_highlight":false,"is_publish_live":false,"is_publish_wemedia":null,"editions":null,"column":"","sentiment":"0","news_tag":"","news_rank":0,"symbols":[],"gpt_button":1},"commentList":[],"isCommentEnd":true,"newsSizeData":{"likeSize":0,"commentSize":0,"repostSize":0,"favoriteSize":0,"likeStatus":false,"favoriteStatus":false},"APP":{"userAgent":"Mozilla/5.0 AppleWebKit/537.36 (KHTML, like Gecko; compatible; ClaudeBot/1.0; +claudebot@anthropic.com)","isDev":false,"isTTM":true,"deviceId":"web-server-community-laohu8-v3","version":"4.30.0","shortVersion":"4.30.0","platform":"web","vendor":"web","appName":"ttm","isIOS":false,"isAndroid":false,"isTiger":false,"isTHS":false,"isWeiXin":false,"isWeiXinMini":false,"isWeiBo":false,"isQQ":false,"isBaiduSwan":false,"isBaiduBox":false,"isDingTalk":false,"isToutiao":false,"isOnePlus":false,"isHuaWei":false,"isXiaomi":false,"isXiaomiWebView":false,"isOppo":false,"isVivo":false,"isSamsung":false,"isMobile":false},"href":"/m/news/2492958931"}