Medicare Advantage Denials

Donna White

Donna White

By Donna White, Principal Consultant and Owner of Legacy Consulting Services and Legacy Billing Solutions in Montgomery, Alabama.

We have talked about managing denials in the past, but have rarely gotten payor specific. In this recent article from, they targeted in on Medicare Advantage plans.

This stems from an investigation by the HHS Office of Inspector General. They have discovered a high number of overturned denials for Medicare Advantage organizations. Three-fourths between 2014-2016 to be clear. That’s three quarters of Medicare Advantage denials appealed and overturned.

Well, the appeals were overturned – so what is the concern? The concern lies with the consideration that both providers and patients are not receiving the reimbursement they should. Some practices do not always follow through with appeals, leaving large amounts of money on the table.

Worse, if providers see a denials trend towards a particular service, they may consider other treatments for patients that do reimburse without additional work. From the provider’s perspective, it is increased overhead costs in the time it takes to work appeals by the billing staff. It is also a delay in cashflow. This could mean patients are not getting the treatments they need.

This report calls to CMS to better govern Medicare Advantage organizations (MAO’s) and take enforcement actions where needed. It was also suggested that CMS inform beneficiaries of MAO’s that violate these regulations. CMS has agreed.
Have you reviewed your Medicare Advantage denials recently? What trends are you seeing? Comment below with your thoughts on additional regulations to MAO’s.

Leave a Comment

Your email address will not be published. Required fields are marked *

Skip to content