Home Resources Our blog Studies Prove That Medicare Advantage Plans Wrongly Denied Care to Beneficiaries
Medicare Advantage (Part C)
Jun 2, 2022

Studies Prove That Medicare Advantage Plans Wrongly Denied Care to Beneficiaries


When it comes to Medicare Advantage plans, some people are all for them, enjoying the lower monthly premiums and additional benefits. On the other hand, some people are completely against them due to the restrictive nature of provider networks and pre-authorizations. Everyone could find different reasons for having this type of plan, but a recent study may make you think twice before considering an Advantage plan.

A shocking new report was released last week by the Office of Inspector General (OIG) concerning the unscrupulous practices of some of the top Medicare Advantage plan carriers. It is important to know that Medicare Advantage plans use a “capitated” payment model. This means that they pay providers a fixed amount up front over time for each patient. Although the practice itself is not unethical, many are worried that this may incentivize carriers to wrongly deny claims in order to keep profits higher. Unfortunately, it seems their concerns may already be a reality.

According to the Centers for Medicare and Medicaid Services (CMS), yearly audits of Medicare Advantage plan carriers have shown “widespread and persistent problems related to inappropriate denials of services and payment.” This prompted the OIG to conduct a random investigation on the top 15 Medicare Advantage carriers. Several experts reviewed hundreds of real-life cases that resulted in denials. What they found was infuriating to say the least.

Regarding pre-authorizations, the OIG concluded that Medicare Advantage plan carriers often “delayed or denied Medicare Advantage beneficiaries’ access to services, even though the requests met Medicare coverage rules”. These cases shed light on strict regulations set by Medicare Advantage plans that were over and beyond what is required by Medicare coverage rules. These strict guidelines ultimately cause delayed care for beneficiaries.

What’s even more frustrating is that some claims did not have the supporting evidence to be approved, but the patient’s medical file had more than enough information to prove the services were medically necessary. Imaging services and injections were among the most common services to be denied. It looks like the burden of pre-authorization was either on the shoulders of the carrier or doctor’s office itself.

Now, when they examined payment request denials, they found that about 18% of claims met Medicare coverage rules and the Medicare Advantage plan’s rules, but still resulted in a denial due to erroneous claims processing. Some of the reasons they attributed this to were human errors like over-looking documents, and system errors when the system used was not updated correctly. It seems like even if you jump through all the hoops, you still have a chance of getting denied services for reasons that are out of your control.

What can you do to ensure you do not fall victim to these sloppy insurance handlings? Stay on top of your care. With over 26 million people currently in Medicare Advantage plans it is easy to slip through the cracks. Hold your insurance company accountable to their processing timelines and make sure they have the documents they need to process your claims. The same diligence needs to be applied to your provider’s office. Be sure to advocate for yourself – if you need to file a grievance or appeal, then do so. Remember, no one is going to push for your best interests but you.

For help with Medicare plans – or any questions you may have about Medicare – contact AMAC’s Medicare Advisory Service at 1-855-611-4856 or request a quote below!

(Please note that we do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.)

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