As enrollment in Medicare Advantage plans continues to surge, so does the alarming rate of inappropriate denials of care.

Many people find Medicare Advantage plans attractive because of their low premiums, ease of one-stop shopping and the extra benefits they offer such as gym memberships, dental and vision care. However, when people choose an Medicare Advantage plan, they should also consider the risk that Medicare Advantage plans frequently deny claims.

When you join an Medicare Advantage plan, the insurer, and not the doctor, determines the medical necessity of your care and defines the terms of coverage. What a Medicare Advantage plan covers today, it may not cover tomorrow. While the Centers for Medicare and Medicaid Services sets broad benefit parameters, Medicare Advantage plans have virtually free reign to delay and/or deny care, even when your treating physician deems your care medically necessary. But this doesn’t mean you should give up the fight when an insurer denies you care. You should file an appeal, and your odds are good that the plan will overturn its decision. That’s the message for consumers in a recent government report examining service and payment denials in Medicare Advantage plans.

Reviewing appeals filed by Medicare Advantage enrollees and health care providers between 2014 and 2016, the U.S. Department of Health and Human Services’ Office of the Inspector General raised serious concerns about inappropriate Medicare Advantage denials of care as well as wrongful payment denials. The findings showed that Medicare Advantage plans overturn their own denial decisions 75 percent of the time; however, most people still don’t file an appeal when their claim is denied. Put differently, 99 percent of Medicare Advantage plan members, who were denied access to care or payment for services they received, simply don’t challenge their denials mainly because they don’t know they have a right to appeal.

An unjustified denial can carry implications — not only for the beneficiary’s health and pocketbook, but also for the physician, who typically must inform the beneficiary when a claim has been denied. Another notable finding in the Inspector General’s ‘s report was that 82 percent of the denials came after, not before, the service was provided. Again, this can put the healthcare provider in an awkward position of having to ask the patient upfront for reimbursement because the insurer is likely to deny treatment.

Audits of Medicare Advantage plans by the Centers for Medicare and Medicaid Services support the Inspector General’s findings that many Medicare Advantage plan members may not be getting the care or coverage to which they are entitled. The centers have found profound and persisting problems with Medicare Advantage plans wrongly denying care. In 2015 alone, the centers found that more than half of all the Medicare Advantage plans they audited (56 percent) inappropriately denied care or payment.

In addition to Centers for Medicare and Medicaid Services internal audits of Medicare Advantage plans, they found that more than four in 10 plans (45 percent) failed to provide their members with appropriate or correct information about their denials, thereby undermining a plan member’s ability to challenge their private insurer. While the centers have the authority is issue monetary penalties that hasn’t deterred insurers from wrongly denying care.

In its report, the Inspector General’s Office recommended theCenters for Medicare and Medicaid Services take stronger and swifter actions against insurers.


It’s critical for an Medicare Advantage enrollee to read the denial notice, understand their rights to appeal and to file an appeal promptly. Follow the instructions on the denial notice to initiate the appeal. A denied claim isn’t the same as a rejected claim. Claims often get rejected when there is missing or incorrect information.

When filing an appeal, supporting documentation from your doctor is vitally important. Your doctor should explain why your care is needed and don’t forget to inform them the timeframes for submitting an appeal. Medicare Advantage plans give you 60 days from the date of the denial notice to file an appeal. This is in contrast to people with traditional Medicare who have 120 days to file an appeal.

Once your appeal is submitted, the Medicare Advantage plan must make their decision within 30 days. If your health could be jeopardized by waiting for the standard appeals process to play out, request an expedited appeal, which requires your plan to make its decision within 72 hours. If your initial appeal does get rejected, you still have several other levels of appeal.

When you enroll in an Medicare Advantage plan it is absolutely essential that you follow the plan’s rules.

You must seek preapproval for certain procedures, exhaust in-network options before going to out-of-network provider and consult with your provider on the medical necessity of your care.

Generally, you can’t be denied coverage if your plan pre-approves your service or treatment, nor can your plan deny you care in the case of a medical a medical emergency.

The key takeaway here is when your Medicare Advantage plan denies care, fight back. Yes, it’s true the appeals process can be overwhelming, especially when a person is sick or frail. Find expert assistance through your State Health Insurance Assistance Program (known as APPRISE in Pennsylvania). To find your local program, call (877) 839-2675 or go to You may also contact the Medicare Rights Center, an advocacy group for Medicare beneficiaries. Go to or call (800) 333-4114.

Joel Mekler is a certified senior adviser. Send him your Medicare questions at

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