Seniors Enrolling in Medicare Advantage Plans Should Consider Rate of Claim Denials

Via the Pittsburgh Post-Gazette:

With six weeks left in Medicare’s open enrollment period, seniors this year are looking at the usual factors as they choose their 2019 coverage — premiums, deductibles and drug costs — plus the prospect of the UPMC-Highmark relationship ending next summer. A recent federal report suggests seniors should consider something else, too: The risk that an insurer will deny their claim. The report from the U.S. Department of Health and Human Services inspector general found that Medicare Advantage insurers subsequently approved patients’ previously denied claims 75 percent of the time from 2014-2016. The fact that 216,000 denials were overturned each year from 2014 to 2016 “raises concerns that some Medicare Advantage beneficiaries and providers were initially denied services and payments that should have been provided,” the report said. While an approval ultimately came most of the time, the report also noted that beneficiaries appealed the original rejections only 1 percent of the time — an indication they may be reluctant to navigate a process that advocacy groups told the HHS inspector general “is often confusing and overwhelming for beneficiaries, particularly those struggling with critical medical issues.” An unjustified denial also can carry implications — not only for the consumer’s health and pocketbook, but for the relationship with a physician who often has to deliver the bad news that a claim has been denied

Source/more: Pittsburgh Post-Gazette