Medicare Advantage plans denied nearly 1 in 5 claims that should have been paid, HHS finds

(CHICAGO SUN TIMES) Ken Alltucker, May 2, 2022

A new government watchdog report has found that private Medicare plans routinely rejected claims that should have been paid and denied services that reviewers found to be medically necessary.

The report , done by U.S. Department of Health and Human Services inspector general’s office investigators, found private Medicare plans denied 18% of claims allowed under Medicare coverage rules. The denials often were a result of errors in processing claims.

The review also found private Medicare plans turned down 13% of authorizations for medical services that government-run Medicare would have allowed.

The inspector general reviewed hundreds of authorization and payment denials by 15 of the largest Medicare Advantage plans over one week in June 2019. Coding experts and physician reviewers examined the cases, and the agency estimated how often insurers denied requests that should have been covered.

Source: Chicago Sun Times