Medicare Advantage Plans Under Scrutiny

Published in VGM Government Relations on June 27, 2024

Medicare Advantage Plans Under Scrutiny for HME Denials

(This post was originally featured in HME News)

The coverage of HME by Medicare Advantage plans has recently come under fire. At the VGM Heartland Conference on June 11, stakeholders highlighted a critical issue; Medicare Advantage plans are allegedly denying coverage unjustly, and there’s a pressing need for data to support these claims.

Dan Fedor, Director of Reimbursement and Education for U.S. Rehab (a division of VGM), advises providers to submit claims through the prior authorization process for traditional Medicare (even for Medicare Advantage patients). This strategy provides ‘ammunition’ if Medicare approves the claim but Medicare Advantage denies it.

A VGM member received a telling response from a Medicare Advantage plan which essentially stated that their independent policies and procedures take precedence over CMS’s determinations. This stance contradicts the expectation that Medicare Advantage plans should follow Medicare coverage guidelines.

VGM Vice President of Payer & Member Relations, Craig Douglas, emphasized that Medicare Advantage organizations are required to cover all Part A and Part B benefits under the same conditions as traditional Medicare (excluding certain services). This CMS language is at the heart of the current dispute. 

The panel urged providers to submit data on these types of denials to help build a case.  Kim Cuce’, Director of Business Optimization for VGM, suggests setting up software processes to flag denials, making data collection more manageable.

Lastly, the presenters also encouraged providers to involve local media outlets and be transparent with patients about the source of the denials, thereby shifting the blame away from themselves and onto the insurance providers.

Check out the full article here: 

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