How to fight a Medicare Advantage Claim Denial

Business publisher Kiplinger reports that inappropriate denials of claims made under Medicare Advantage (MA) plans are “a growing concern.” One reason is simply because enrollments in MA plans continue to surge, after more than doubling in the decade between 2011 and 2021 to some 26 million enrollees. Which leads, of course, to more claims in sheer numbers. On the plus side, Kiplinger says your odds are good that if you file an appeal of a denial, your plan will overturn its decision. The Inspector General of the U.S. Department of Health and Human Services reported that in one recent two-year period, fully 75% of claim denials were overturned when the patient appealed. But the report also noted only about 1% of denials ever get appealed, suggesting, as Kiplinger says, that “some beneficiaries may be going without needed services.” What should you do when your claim is denied? First of all, read denial notices carefully, file appeals promptly, and follow directions you’re given when making your appeal. There is a fairly tight window in which you can file an appeal. Audits have found that close to half of MA plan denial notices have incomplete or incorrect information. Be watchful for it. Kiplinger says if your appeal is rejected, your claim will be automatically forwarded to an independent review, with still further appeals possible. If all appeals fail to resolve your issue, you can seek assistance at your state health insurance program (in Colorado see https://www.cohealthinfo.com/). Or contact the Medicare Rights Center at https://www.medicarerights.org/.