Every year, tens of thousands of people enrolled in private Medicare Advantage plans are denied necessary care that should be covered under the program. A government watchdog report found private Medicare plans routinely rejected claims that should have been paid. These plans often denied services that were medically necessary.
Not only are many seeing managed care plans increase payment denials, some observers say they’re often doing it without justifiable cause. For profit insurance denied 18% of claims allowed under Medicare coverage rules.
The U.S. Department of Health and Human Services inspector general investigators completed the report. Federal investigators urged Medicare officials to strengthen oversight of these private insurance plans.
These private for profit companies provide access to benefits for 28 million older Americans. Advantage plans are a popular option among older Americans. It is privatized Medicare. Less expensive with a wider array of benefits than the traditional government-run program.
However, oversight and transparency is necessary to enforce fairness and prohibit systemic and inappropriate denials of care. The profit margin always result in cost cutting and short cuts that cut staffing and care.
One major issue with significant consequences: Insurers’ case managers may exert pressure on staff to alter case mix calculations or even primary diagnosis codes so payer pays.