Appallingly High Medicare Advantage Appeal Overturn Rate Implies Improper Denial Practices

OIG recommended more CMS audits and better oversight of MA plans

The Department of Health and Human Services (HHS) Office of Inspector General (OIG) is out with a report analyzing the rate Medicare Advantage plan claim denials are successfully appealed. According to the OIG, over 75 percent of appealed denials are successfully overturned.

According to OIG, the “high numbers of overturned denials upon appeal, and persistent performance problems identified by CMS audits, raise concerns that some beneficiaries and providers may not be getting services and payment that MAOs are required to provide.”

Specifically, the OIG found that when Medicare beneficiaries or providers appealed preauthorization and payment denials, Medicare Advantage Organizations (MAOs) overturned 75 percent of their own denials during 2014–16, overturning approximately 216,000 denials each year.

Seventy percent of appeals were fully successful, and five percent were partially successful. The remaining 25 percent were unsuccessful.

The OIG went on to describe how these findings are “especially concerning because beneficiaries and providers rarely used the appeals process designed to ensure access to care and payment, appealing only 1 percent of denials during 2014-16.”

Further, OIG found that this trend continued beyond the MAO level of appeals. The report found that “during the same period, independent reviewers at higher levels of the appeals process overturned additional denials in favor of beneficiaries and providers. The high number of overturned denials raises concerns that some Medicare Advantage beneficiaries and providers were initially denied services and payments that should have been provided.” Independent reviewers overturned an additional 80,000 denials in favor of beneficiaries and providers, which equates to approximately 27,000 per year.

The appeals were successful for several common reasons. CMS cited some MAOs for making the wrong clinical decision based on the information submitted by the provider or beneficiary. CMS also cited MAOs for not conducting appropriate outreach before making clinical decisions, meaning that the MAO did not have all the information needed to decide and did not take appropriate steps to gather information from the provider or beneficiary.

The OIG recommended that CMS:

  1. Enhance its oversight of MAO contracts, including those with extremely high overturn rates and/or low appeal rates, and take corrective action as appropriate;
  2. Address persistent problems related to inappropriate denials and insufficient denial letters in Medicare Advantage; and
  3. Provide beneficiaries with clear, easily accessible information about serious violations by MAOs.

CMS concurred with all three recommendations. As always, ADVOCATE will keep you up to date on this and all issues impacting radiology as they become available.

Best regards,
Kirk Reinitz, CPA 
President/CEO