Watchdog: Private Medicare plans denied nearly 1 in 5 claims that should have been paid

USA TODAY – A government watchdog report released Thursday found private 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 investigators, 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 report found.

The review also found private Medicare plans turned down 13% of authorizations for medical services that government-run Medicare would have allowed.

A government watchdog report found private Medicare plans rejected 18% of authorization requests and claims that traditional government-run Medicare allowed. (Story continues below …) 

The largest Medicare Advantage plan providers in 2021, according to a report by KAISER FAMILY FOUNDATION:

  • UnitedHealthcare

  • Humana

  • BCBS plans

  • CVS Health

  • Kaiser Permanente

  • Centene

  • Cigna

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(Continuation of USA TODAY story … ) 

The inspector general reviewed hundreds of authorization and payment denials by 15 of the largest Medicare Advantage plans over one week in June 2019.

Coding experts and physician reviewers examined the cases, and the agency estimated how often insurers denied requests that should have been covered.

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 – such as first requiring an X-ray before allowing other scans such as an MRI.

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The plans also claimed the request lacked appropriate documents, but investigators said beneficiaries’ medical records were enough to support these requests.

The inspector general concluded the agency that oversees Medicare should tighten oversight, issue new guidance for clinical reviews employed by private Medicare plans and order private plans to fix vulnerabilities that can lead to review errors … READ MORE. 

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