03/01/2024
Medicare Advantage Denials: What You Can Do
One of the most common complaints we hear from healthcare providers is the troubling trend of high claim denial rates in the Medicare Advantage plan space. A specific trend that we have observed over the last year is MA plans applying their own coverage criteria to claims where fee-for-service Medicare has clearly articulated coverage policies spelled out in a Local Coverage Determination/Policy Article.
Can MA plans assert their own coverage criteria? Are they required to follow FFS Medicare's standards?
What You Need to Know
Some MA plans deny authorizations/claims based on coverage criteria that (a) they've created on their own, and (b) are more restrictive than Medicare's requirements as spelled out in LCD's and Policy Articles. The reason they do this is because only a small percentage of all denials actually get appealed. A Kaiser Family Foundation analysis of MA plan data last year indicated that health care providers appeal only 11% of denied claims, even though when they do file appeals, they prevail in whole or in part more than 80% of the time.
However, MA plans are required to follow Medicare coverage policy when that policy is spelled out in a National Coverage Determination or Local Coverage Determination/Policy Article.
Medicare has a “longstanding policy that MA organizations may only apply coverage criteria that are no more restrictive than Traditional Medicare coverage criteria found in NCDs, LCDs, and Medicare laws.”
What Does This Mean for You?
When you receive a MA plan denial, you must first ascertain the basis for that denial. If it references a medical policy or cites coverage criteria, you should confirm that the standards listed in that policy or criteria are no more restrictive than those in the applicable LCD or Policy Article. We have seen many examples where the standards are similar to LCD/PA criteria, but ultimately not the same.
If you determine that the MA plan is applying coverage standards that FFS Medicare would have paid for, your appeal of the denial should include an explicit argument that the MA plan is not complying with established Medicare regulations. You should cite one or more of the paragraphs quoted above in your appeal to bolster your arguments.
On the other hand, remember that if no NCD or LCD/PA exists, then MA plans do have the authority to create applicable coverage standards. So, for example, upper extremity prostheses do not currently have a NCD or LCD/PA that set forth relevant coverage criteria. In that instance, a MA plan applying its own criteria would be operating within the scope of authority granted to it by Medicare.
Denials are frustrating.
By utilizing the resources provided in this article, you can increase the chances of a successful appeal by following the recommendations we've given.
