Medicare Advantage Plans Under Scrutiny

Published in Government Relations on June 27, 2024

Medicare Advantage Panel

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: 

MEDICARE ADVANTAGE: INDUSTRY FIGHTS BACK

From Our Experts

VGM Submits Comments Regarding the Section 232 National Security Investigation On Medical Imports thumbnail VGM Submits Comments Regarding the Section 232 National Security Investigation On Medical Imports VGM has submitted formal comments to the U.S. Department of Commerce in response to its Section 232 National Security Investigation into the importation of personal protective equipment (PPE), medical consumables, and medical equipment and devices. Senate Backs DME Relief Act with Bipartisan Support thumbnail Senate Backs DME Relief Act with Bipartisan Support In a significant development for the durable medical equipment (DME) industry and Medicare beneficiaries, the U.S. Senate has introduced S.2951, the companion legislation to H.R. 2005, known as the DMEPOS Relief Act of 2025. The Senate bill is being led by Senator James Lankford (R-OK) and has gained bipartisan support with Senator Maggie Hassan (D-NH) joining as a co-sponsor. Gov't Shutdown: What It Means for Providers thumbnail Gov't Shutdown: What It Means for Providers As expected, Democrats and Republican members of the Senate was unable to agree on terms in passing a continuing resolution (CR) ahead of the October 1st deadline, resulting in a government shutdown. But how did we get here? Oppose DMEPOS Bidding Expansion – Take Action Now thumbnail Oppose DMEPOS Bidding Expansion – Take Action Now A critical Congressional Sign-On Letter is now circulating in the House of Representatives, led by Reps. Neal Dunn (R-FL) and Greg Murphy (R-NC). This bipartisan letter calls on CMS to stop the proposed expansion of the durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) Competitive Bidding Program to include ostomy and urological supplies. Gov't Shutdown & Telehealth Flexibility Expiration thumbnail Gov't Shutdown & Telehealth Flexibility Expiration September 30 represents an important date for HME providers for two reasons: 1) The potential of a government shutdown and how that affects HHS and CMS, and 2) the expiration of Telehealth Flexibilities unless a Continuing Resolution (CR) is agreed upon in time. Josh Turek Visits VGM to Champion Accessibility & Advocacy thumbnail Josh Turek Visits VGM to Champion Accessibility & Advocacy Waterloo, IA — On Monday, VGM Group hosted the first of our “Meet The Candidate” forums by welcoming Iowa State Representative Josh Turek, a Democratic candidate for the U.S. Senate seat soon to be vacated by Senator Joni Ernst. VGM & NCART Rally in D.C. to Defend CRT & HME Access thumbnail VGM & NCART Rally in D.C. to Defend CRT & HME Access Washington, D.C. – September 2025 — A powerful few days of advocacy wrapped up in the nation's capital as representatives from VGM Group, NCART, AAHomecare, and other key stakeholders in the Complex Rehab Technology (CRT) and Home Medical Equipment (HME) industries met with lawmakers to address urgent policy concerns. Igniting Champions Of Change During August Recess thumbnail Igniting Champions Of Change During August Recess This August recess, DME suppliers across the country seized the opportunity to engage with lawmakers and advocate for critical DMEPOS legislation. Their efforts are helping to build momentum and expand the network of congressional supporters.