Medicare Advantage Denials

The Medicare Advantage (MA) program allows Medicare beneficiaries to receive benefits through private plans rather than the traditional fee-for-service (FFS) program. While this may sound simple in principle, the hybrid nature of the program, combining commercial insurance practices and Medicare regulations (not always harmoniously), presents a unique set of challenges when confronting denied or underpaid claims. MA plans can use selective contracting and utilization management to coordinate and manage care and control service use. Some plans offer a uniform benefit package and premium across a designated region while others vary their premiums and benefits across counties. There are thousands of MA plans offered under the program, each with its own set of rules.

When denied MA claims are received by Fotheringill & Wade (F&W), an Attorney will review the claims to determine the appropriate course of action. The determined course of action will take into account the provider’s relationship with the plan as well as the nature of the denial – clinical, administrative, technical, or mixed. The strategy for pursuing the claims will be entered into Quantum Appeals, our proprietary claims management software, along with applicable due dates for any necessary appeals. If the appeal or claim analysis requires clinical expertise, the case is sent for review by one of the clinicians on our team (physician, physician’s assistant, or registered nurse).

Once an appeal has been drafted, an Attorney reviews the appeal and, if necessary, adds Federal or contractual language to the appeal. Once approved, the appeal is sent and the case is assigned to a Recovery Specialist who follows-up to ensure that the appeal is received and addressed by the Insurer in a timely manner. Each case is continually audited by an Attorney or Reimbursement Analyst to ensure that the appeal process is proceeding appropriately. In the event of an unfavorable decision, F&W will continue appealing meritorious cases through the appropriate levels.

Contracted Providers

Being contracted means being more accessible for plan enrollees, but it also generally means more limited appeal rights. When denied claims are received by F&W, our attorneys will review your contract with the MA provider to ensure that all avenues for appeal are being utilized. Our attorneys will also consult with hospitals on contractual matters to ensure that provider’s achieve the most favorable terms with payers.

Non-Contracted Providers

Providers who are not contracted generally hold greater rights of appeal than contracted providers. Non-contracted providers can request independent review of a claim (i.e. that a person without a financial stake decide whether or not a claim should be paid). Non-contracted providers can also appeal unfavorable decisions to an Administrative Law Judge or the Medicare Appeals Council.

Audits

One of the principles behind Medicare Advantage was that plans could save Medicare money by reducing utilization prior to services being rendered. However, many plans still maintain robust programs that audit and deny claims months or years after payment. Some MA providers subcontract audit responsibilities to the Medicare Recovery Audit Contractors (RACs).

Tracy Wade

 

Sarah Mendiola