Medicare Advantage Appeal Outcomes

Something important to know, it can really pay to appeal a Medicare Advantage denial of coverage since chances are good the denial will be overturned if the claim is legitimate. 

When beneficiaries and providers appealed preauthorization and payment denials, Medicare Advantage Organizations (MAOs) overturned 75 percent of their own denials during 2014 to 2016 according to a report from the Office Of Inspector General (OIG).

During the same 
period, independent reviewers at higher levels of the appeals process overturned additional denials in favor of beneficiaries and providers.1

Beneficiaries and providers rarely used the appeals process, which is designed to ensure access to care and payment. During 2014 to 2016,
beneficiaries and providers appealed only 1 percent of denials to the first level of appeal.1

When Medicare Advantage beneficiaries and providers appealed, they were usually successful in getting denials overturned!1

So bottom line: If you feel you have had a legitimate Medicare Advantage claim denied, file an appeal! You should be able to contact your Medicare Advantage customer service via the phone number on the back of your member card to find out the process to appeal for your specific plan and company.

1. Source: Report in Brief U.S. Department of Health and Human Services, September 2018 OEI-09-16-00410 (Office of Inspector General)

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