OIG Report – Medicare “Advantage” Organizations Restrict Beneficiary Access to Medically Necessary Services

Published in Complex Rehab on May 18, 2022

By Dan Fedor, director of reimbursement and education for U.S. Rehab.

I’ve written several articles over the past two years on Medicare Advantage (replacement plan) due to the overwhelming number of complaints from HME suppliers regarding denials, underpayments, and delays in payment from many of these plans, in which I like to refer to them as DIS-Advantage Plans or replacement plans. I don’t think we should accept using the word "advantage" as we talk about these plans since that seems to be their marketing team’s goal in misleading Medicare beneficiaries about their plans being an advantage. It’s NOT in most cases, and a recent report from the Office of the Inspector General (OIG) confirms what our industry has been experiencing and has been raising concerns about for several years, and it's only getting worse. Note this report is from data pulled in 2019, so as you can imagine even though it reflects badly on these plans, it’s much worse today. 

Here are some bullet points from the OIG report. The full report file is at the end of this article. 

  • Random sample of 250 prior authorization denials and 250 payment denials issued by 15 of the largest MAOs during June 1-7, 2019
  • Determined that MAOs sometimes delayed or denied Medicare Advantage beneficiaries' access to services, even though the requests met Medicare coverage rules
  • Denied requests that meet Medicare coverage rules may prevent or delay beneficiaries from receiving medically necessary care and can burden providers
  • Prior authorization requests that MAOs denied, 13 percent met Medicare coverage rules; in other words, these services likely would have been approved for these beneficiaries under original Medicare

OIG Recommend that CMS:

  • Issue new guidance on the appropriate use of MAO clinical criteria in medical necessity reviews;
  • Update its audit protocols to address the issues identified in this report, such as MAO use of clinical criteria and/or examining particular service types; and
  • Direct MAOs to take additional steps to identify and address vulnerabilities that can lead to manual review errors and system errors

Assisting the Beneficiary when medically necessary services are denied, underpaid, or delayed:

  • Attempt to work with the Medicare Replacement regarding the issue BUT if that doesn’t work
  • If the beneficiary is dual eligible and has Medicaid they can change once per quarter to original Medicare FFS (don’t have to wait for open enrollment)
  • If there is a different Medicare Replacement plan in their area that is a 5 star plan they can change to that company anytime if there are documented issues of being denied services that are medically necessary
  • Have the beneficiary call Medicare and request to file a formal complaint with details 1-800-Medicare
    • What was promised in the policy (the sales pitch)
    • What was not provided and when (be specific)
    • Indicate they feel they were deceived/mislead by the MA if they feel that way
    • Inform Medicare that the Medicare Replacement Plan isn’t DY-NO-MITE as Jimmy JJ Walker leads people to believe  
    • Request to change to Medicare FFS immediately in order to obtain the medically necessary services needed

This OIG report gives our industry some validation that these Medicare Replacement plans policies ARE negatively impacting Medicare Beneficiaries in receiving medically necessary services. If you encounter this situation, please be sure to notify your congressional representative with specifics and cite this OIG report to support what you are experiencing. 

VGM and U.S. Rehab plans to prepare a more formal playbook on this topic as we realize that this is one of the top challenges in our industry. 

If you have any questions or comments, please contact me at [email protected] or 570-499-8459. 

Full OIG Report Apr 2022


TAGS

  1. billing & reimbursement
  2. cms
  3. complex rehab
  4. dmepos
  5. medicare
  6. reimbursement

From Our Experts

Audit Forecast: Recent Publications and Activities Hint at Audit Increases Across Multiple Payers thumbnail Audit Forecast: Recent Publications and Activities Hint at Audit Increases Across Multiple Payers There are a number of signs that are pointing to an increase in audit activity across multiple payers as the public health emergency (PHE) winds down. Stakeholders: ‘We Want To Fix This Issue For Good' thumbnail Stakeholders: ‘We Want To Fix This Issue For Good' Complex rehab stakeholders, including NCART, AAHomecare, U.S. Rehab and state and regional associations, are working on a more comprehensive strategy for service and repair reform. Heartland Conference 2023: Session Sneak Peek thumbnail Heartland Conference 2023: Session Sneak Peek Every year, the VGM Heartland Conference delivers a one-of-a-kind learning experience with the best education in the DMEPOS industry. Packer Perspective: Supporting Medicare Coverage of Seat Elevation Systems thumbnail Packer Perspective: Supporting Medicare Coverage of Seat Elevation Systems Greg Packer, President, U.S. Rehab, shares the importance of submitting comments to CMS on the seat elevation proposed rule. Time is Almost up to Send in Comments over Medicare Coverage of Seat Elevation Systems thumbnail Time is Almost up to Send in Comments over Medicare Coverage of Seat Elevation Systems The comment period is set to go for ONE MORE WEEK! All comments must be in by the end of the day Friday, March 17. Understanding the Driver of Your Workers' Compensation Premium Expense thumbnail Understanding the Driver of Your Workers' Compensation Premium Expense Jim Nygren, President, VGM Insurance Services, discuss the Workers' Compensation Experience Modification and how this factor impacts your premiums. Forecasting. It's Here to Stay: 5 Things Everyone Should Know thumbnail Forecasting. It's Here to Stay: 5 Things Everyone Should Know Forecasting. It's one of the biggest buzzwords in the data world today, and it's only going to grow throughout the next year and beyond. Can Outsourced Solutions Be the Answer to the Challenges Facing DMEPOS Providers in 2023? thumbnail Can Outsourced Solutions Be the Answer to the Challenges Facing DMEPOS Providers in 2023? How does a business owner facing certain challenges build a strategy to grow their business or improve profit margins? Perhaps it's time for your business to consider outsourcing.