Don't Let This Medicare Advantage Glitch Cost You

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If you, or a parent, or just someone you care about is enrolled in a Medicare Advantage plan, you need to be aware of a glitch that can cost you plenty if you're not persistent.

Unlike Original Medicare, Medicare Advantage (MA) plans typically require getting prior authorization for medical care. A major survey by the non-profit Kaiser Family Foundation reports that more than 2 million out of over 35 million prior authorization requests were fully or partially denied.

That's "only" six percent or so, but just to be clear that's the average among major insurance companies running MA plans. A few individual insurers denied more than 10% of prior authorization requests.

Now here's the most important point: When enrollees (or their medical providers) appealed a denial, it was overturned fully or partially more than 8 out of 10 times. Let that sink in - people who took the time to push back and challenge, "won" more than 80% of the time.

That sure seems like the profit-focused insurance companies are playing some sort of game where they are hoping folks will just walk away or pay for something out-of-pocket. But when an enrollee appeals a denial, the insurer much more often than not agrees to cover the procedure.

Insurers are rewarded for that strategy. The same survey found that just 11% of denied prior authorizations were challenged. Let's flip that - 89% of enrollees who weren't granted a prior authorization didn't push back.

Look, I wish this wasn't the way MA worked. The fact that more than 80% of denials were reversed in 2021 sure seems to signal that the system is broken. And the cost to medical offices that do challenge denials is another unnecessary drain on a part of our healthcare system that is already stretched thin. But this is where we are at.

If you or someone you know is enrolled in MA and is told a pre-authorization request has been denied, the takeaway is to push back and file an official appeal.

You should receive a Notice of Denial of Medical Coverage from the insurer. That form should include directions on how to appeal. If not, contact the insurer and ask for instructions on how to proceed. You may be able to do it over the phone, but more likely you will need to submit some paperwork. You have 60 days to file your appeal, and the insurer has 30 days to respond. You can also ask for an "expedited" decision if you have a pressing medical need. And it can help your case if your care provider chimes in with a letter stating why the procedure is necessary.

"Don't Let This Medicare Advantage Glitch Cost You" means that there is a problem or mistake in the Medicare Advantage program that could end up costing you money. The message is advising people to be aware of the glitch and take steps to prevent any financial loss.

What is Medicare Advantage?

Medicare Advantage, also known as Medicare Part C, is a type of health insurance offered by private companies that contract with Medicare to provide coverage for medical expenses. This type of plan offers additional benefits that are not available with Original Medicare, such as vision, dental, and prescription drug coverage.

The Medicare Advantage Glitch

The Medicare Advantage glitch is a billing error that occurs when a provider bills Medicare for services that should be covered by the Medicare Advantage plan. This can result in the provider receiving a lower reimbursement rate than they would have received if they had billed the Medicare Advantage plan directly.

The glitch can also result in the patient being responsible for higher out-of-pocket costs, as Medicare may not cover services that should have been covered under the Medicare Advantage plan. This can be particularly problematic for patients with chronic conditions or those who require frequent medical services.

How to Avoid the Medicare Advantage Glitch

To avoid the Medicare Advantage glitch, it's important to make sure that your healthcare providers are aware of your Medicare Advantage plan and that they bill the plan directly for any services that are covered. You should also review your plan benefits and coverage information regularly to ensure that you are receiving the benefits you are entitled to.

It's also a good idea to keep a record of all medical services received, including the date of service, the provider's name and address, and the services provided. This can help you identify any billing errors and ensure that you are not overcharged or undercharged for medical services.

Final Thoughts

The Medicare Advantage glitch can be costly for both providers and patients, but it can be avoided with careful attention to billing and coverage information. By working with your healthcare providers and staying informed about your plan benefits, you can ensure that you are receiving the care you need without incurring unnecessary expenses.