Ophthalmology and Optometry Coding Alert

Question: We’ve been seeing an increase in denials for Medicare Advantage lately. Has something changed in the program or the claim processing that we need to accommodate for?

Codify Subscriber

Answer: It’s possible that you truly are seeing an uptick in your Medicare Advantage (MA) denials, but the problem is likely not something that you can fix with your claim processing processes.

In fact, the Office of Inspector General 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.

If you’re seeing inappropriate denials for patients who have MA, you are fully within your rights to appeal. Ask the ophthalmologist to help write a letter describing why the service is medically necessary and how it will contribute to the 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.