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CORRECTION: VGM Government and OPOLE Create A Guide to Submitting Medicare Advantage Organization (MAO) Complaints

Published in Government Relations on June 26, 2023

Due to the significant number of reports that we have received over the past several months regarding the tactics being employed by several Medicare Advantage Organizations (MAOs) to deny both authorization requests and claims for several important categories of DME, VGM is collaborating with OPOLE to provide you with some helpful resources regarding MAO related complaint submission. OPOLE (Office for Program Operations and Local Enforcement) is a division within CMS which provides a level of contract oversight and acts as a communication channel between CMS and MAOs. VGM has been actively communicating with OPOLE and has provided them with examples of MAO auth and claim denials. We understand the urgency surrounding these issues and have been talking with them about the best process to resolve them. In addition to those efforts, several of our members have asked for a mechanism through which they can report these issues and file complaints directly themselves. To that end, OPOLE staff has provided us with some guidance regarding the process through which formal complaints can be submitted.

Attached to this message, you will find a couple of resource documents aimed at streamlining the process for submitting complaints regarding MAOs to CMS staff. The documents outline the complaint submission process, the data elements which must be included in the complaint, and who the point person is for your complaint based on your state/region. Your timely complaint submission will contribute to better and more timely healthcare for the patients that you serve. Together, let’s drive positive change!

External Provider Complaints Rule

OPALE State Association Contacts

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