A government watchdog report released April 28th found private insurance Medicare plans routinely rejected claims that should have been paid and denied services that reviewers found to be medically necessary. The report, completed by U.S. Department of Health and Human Services inspector general office, discovered private Medicare plans denied 18% of claims allowed under Medicare coverage rules. The denials often were a result of errors in processing claims. The review also found private Medicare plans turned down 13% of authorizations for medical services that traditional government-run Medicare would have allowed. Private insurance Medicare plans are also called Medicare Advantage and Medicare Part C plans.
The report cited two reasons private Medicare plans rejected authorizations that the watchdog’s agency’s physician reviewers found to be medically necessary. The private plans had coverage formulas beyond what Medicare required – for example, first requiring an X-ray before allowing more complex imaging like an MRI. The plans also claimed the request lacked appropriate documents, but investigators said beneficiaries’ medical records were adequate. Doctors and patients frequently appeal the routine claims and care denials lead to extra work and an increasing administrative burden.
The inspector general concluded that the agency that oversees Medicare should tighten
oversight of Medicare Advantage Plans. This should include new guidance for clinical reviews and fixing vulnerabilities that can lead to review errors. Rosemary Bartholomew, a Medicare Advantage expert who led the team that wrote the report, said beneficiaries may be denied care they need or might have to pay for services that their plans should cover.
Listen to the full report below:
Contact: Dick Needleman, Health reporter, 103.3 AshevilleFM, [email protected]
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