Medicare Compliance & Reimbursement

Are you seeing an uptick in your Medicare Advantage (MA) denials? This might be the reason.

The HHS Office of Inspector General (OIG) added a topic to its Work Plan last month noting that the capitated payment model Medicare Advantage uses may incentivize payers “to inappropriately deny access to, or reimbursement for, health care services in an attempt to increase profits for managed care plans.”

Therefore, the OIG is reviewing records to determine whether some MA preauthorizations or claims are being denied, despite being medically necessary. “To the extent possible, we will determine the reasons for any inappropriate denials and the types of services involved,” the OIG wrote.

Tip: If you’re seeing inappropriate denials for patients who have MA, you are fully within your rights to appeal. Write a letter describing why the service is medically necessary and how it will contribute to your patient’s overall health, and send that to the MA medical director, along with documentation proving medical necessity for the service.

Resource: To see the OIG Work Plan item, visit https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000299.asp.