Medicare Appeals

With nearly 84% of physicians accepting Medicare patients, Medicare timely filing denials can affect almost any provider. Medicare Advantage plans are available through private insurance companies that contract with Medicare. Notwithstanding the UBH denial, providers continued the beneficiaries' inpatient care and made claims for reimbursement, which UBH denied. For example, OIG observed among 18 MAOs that the organizations collectively denied 2.4 million pre-authorization and payment requests but only received 1,838 appeals.

The process of filing a Medicare appeal depends on what type of plan you have. Call Member Services at 855-442-9940 weekdays, from 7:00 a.m. to 8:00 p.m., and Saturdays, from 9:00 a.m. to 2:00 p.m. The September 25 report details an OIG study undertaken to address concerns that MAOs are inappropriately denying authorization of services for beneficiaries or payments to providers.

The high overturn rates are a sign of persistent claim denial problems in the Medicare Advantage program, the report stated. If you are unhappy with the Council Review, you may ask a Federal Court Judge to review your case, This is the fifth level appeal. Your Medicare Advantage health plan refuses to cover or pay for services you think your Medicare Advantage health plan should cover.

High denials place a How to Appeal Medicare Advantage Denial burden on the beneficiary to take steps to appeal claims. By inappropriately denying authorization and payment for medically necessary services, MAOs are both harming beneficiaries and potentially misusing Medicare funds, the OIG said. You must request the appeal within 60 calendar days from the date of the decision.

The start date for a particular Medicare claim is considered to be the date the service is provided to the patient or the From” date recorded on the claim form. Every year, Medicare evaluates plans based on a 5-Star rating system. When a doctor requests an expedited appeal, the Medicare Advantage plan must review the case within 72 hours.

The Office of Medicare Hearings and Appeals (OMHA) handles these appeals. Every Medicare Advantage plan must provide Medicare Part A (hospital insurance) and Part B (medical insurance) to its members. If your Medicare Advantage plan does not reverse its denial, the appeal must be forwarded to an Independent Review Entity (IRE) within 24 hours by the MA plan.