Medicare Advantage Insurers Routinely Issue Improper Payment Denials, OIG Finds
With nearly 84% of physicians accepting Medicare patients, Medicare timely filing denials can affect almost any provider. If you're enrolled in a Medicare Advantage (Medicare Part C) plan, file your appeal through that plan. CDPHP refers to both the Capital District Physicians' Health Plan, Inc., a Medicare-approved HMO plan, and CDPHP Universal Benefits®, Inc., a Medicare-approved PPO plan.
In 2015 alone, CMS found that more than half of the Medicare Advantage plans they audited (56 percent) inappropriately denied care or payment. If you have prescription drug coverage through a stand-alone Medicare Part D Prescription Drug Plan, file your appeal through your Medicare Part D Prescription Drug Plan.
If your health plan does not change its decision, then the health plan must send your case file to MAXIMUS Federal Services for a second level appeal, called an External Review. The majority of people, who buy their own health insurance, rely heavily on the insurance agent selling the policy to explain the plan's coverage and benefits.
If you think that your Medicare Advantage program's refusal is jeopardizing your health, ask for a "fast decision." The insurer is legally bound to get you a response within 72 hours. 30 to 60 days for payment of a denied bill. When a claim is denied, review the original submission.
You must file a request for redetermination within 120 days from the date you received the MSN. Of the roughly 216,000 overturned denials, more than 80% were payments to providers for services the beneficiary had already received. Roughly one-third of Medicare beneficiaries are currently signed up for Medicare Advantage (MA) plans, the private-insurance alternative to the traditional Medicare program.
It lists all your items and services that How to Appeal Medicare Advantage Denial providers and suppliers billed to Medicare during that 3-month period, how much Medicare paid, and how much you may have been charged and how much you may owe the provider or supplier. It is provided as a general resource to providers regarding the types of claim reviews and appeals that may be available for commercial and Medicaid claims.