HHS: Medicare Advantage Plans Improperly Denying Claims

Roughly one-third of Medicare beneficiaries are currently signed up for Medicare Advantage (MA) plans, the private-insurance alternative to the traditional Medicare program. That figure is growing rapidly, too, especially as more Americans become aware of the non-medical, at-home care services available through MA plans as supplemental benefits starting in 2019.

While popular, the MA program isn’t without its flaws.

A recent U.S. Department of Health and Human Services (HHS) investigation revealed that some MA plans have improperly denied medical claims to patients and physicians alike. The New York Times highlighted the investigation in a report published Saturday.


Private MA plans, which now cover more than 20 million people, have an incentive to deny claims “in an attempt to increase their profits,” the HHS investigation revealed. Broadly, HHS investigators found “widespread and persistent problems related to denials of care and payment in Medicare Advantage,” the report said.

Allegations related to MA plans denying claims come as the annual open enrollment period kicks off. The period gives beneficiaries a chance to join Medicare Advantage plans, switch plans or return to traditional Medicare.

In general, relatively few people appeal the denial of claims, leaving insurers free to avoid payment, The New York Times reported. Individuals who do appeal often succeed, however, with about three-quarters of appeals succeeding at the first level of review.


“Because Medicare Advantage covers so many beneficiaries, even low rates of inappropriately denied services or payment can create significant problems for many Medicare beneficiaries and their providers,” stated the HHS in its investigation.

Trailing-edge baby boomers — those born later than their leading-edge generational peers — are more likely to enroll in an MA plan, according to the most recent quarterly trends report from Excel Health. Roughly 58% of trailing-edge baby boomers express some level of dissatisfaction with their health coverage.

In the past couple years alone, Medicare has levied more than $10 million in fines and taken other enforcement actions against private plans for overcharging beneficiaries, denying or delaying coverage for prescription drugs and failing to respond to patients’ complaints, The New York Times reported

Although CMS has opened the door for non-medical home care under the Medicare Advantage program, business opportunities remain limited for hospice providers. A hospice MA “carve-in” may be inevitable, though, experts and industry stakeholders predict.

HHS isn’t the only organization questioning the increasing role of Medicare Advantage. Some critics have argued that expanded home care opportunities under MA should have come under traditional Medicare instead.

“Once again, these additional or supplemental benefits are being offered in Medicare Advantage,” Medicare Rights Center President Joe Baker told Home Health Care News in August. “They’re not being offered in the traditional Medicare program — where still the majority of beneficiaries are enrolled — and we really think there should be an even playing field so people have a real choice.”

Written by Robert Holly

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