This second installment in our helpline trends report series examines another worrying theme: erroneous Medicare Advantage (MA) and Part D denials. In 2020-2021, this issue accounted for nearly one-third of all calls to Medicare Rights’ helpline. Of those, 65% were about how to appeal a plan’s decision.
Many callers did not understand the web of appeal rules and timelines, or even how to begin the process. Navigating these intricacies can be particularly overwhelming in times of significant stress or medical need, and the system is not built to adapt quickly. During the pandemic, for example, callers frequently expressed frustration in their inability to comply with strict deadlines, given that many providers’ offices were temporarily closed or operating with reduced hours.
In the best of circumstances, appealing a denial can be difficult and time-consuming; it’s an outdated, taxing process that often leads to delays in care. Troublingly, some MA and Part D plans engage in behaviors that force enrollees into this broken system. Among the most egregious are instances in which plans deny coverage for insufficient or incorrect reasons, requiring beneficiaries to then appeal those bad decisions and go without needed, appropriate care in the interim.
A recent report from the Department of Health and Human Services Office of Inspector General (OIG) found inappropriate denials to be widespread. Previous OIG analysis reached similar conclusions and found that although only 1% of beneficiaries appeal, 75% of those appeals are successful.
Importantly, even reversals come at a cost. The most significant risks are care delays and the resulting negative health outcomes. But appeals processes are also burdensome for beneficiary and provider alike, creating strain, expense, and extra work. Low appeal rates suggest that many beneficiaries abandon the process altogether, along with the care they need. And when plans systematically and inappropriately deny claims, it may have a chilling effect on providers’ willingness to prescribe or provide a treatment or cause providers to spend additional time and resources “over proving” claims to avoid denials.
Medicare Rights urges policymakers to address the well-documented problem of inappropriate plan denials. Without intervention and deterrence, these harmful practices and the risks they pose will only proliferate, especially as MA plans grow in popularity. As OIG notes: “A central concern about the capitated payment model used in Medicare Advantage is the potential incentive for Medicare Advantage Organizations (MAOs) to deny beneficiary access to services and deny payments to providers in an attempt to increase profits.”
People with Medicare must be able to access the care they need, when they need it, and plans must not be permitted to gain financially by denying that care. To that end, Medicare Rights supports a stepping up of federal plan oversight, including audits of coverage denials and more significant sanctions for patterns of inappropriate coverage decisions. We also support notifying beneficiaries and the public about plan violations and offering enrollment relief where needed.