Medicare Advantage Plans Denying Medical Services to Maximize Profits / by Joe Furia

Ann-Marie Alameddin, Vice President of Strategy and General Counsel

A recent Department of Health and Human Services Office of Inspector General (HHS OIG)  report indicates Medicare Advantage plans could be denying medical services to maximize profits. According to the report, when beneficiaries and providers appealed preauthorization and payment denials, Medicare Advantage organizations overturned 75 percent of their own denials between 2014 and 2016. "The high number of overturned denials raises concerns that some Medicare Advantage beneficiaries and providers were initially denied services and payments that should have been provided," said the HHS OIG in the report. "MAOs may have an incentive to deny preauthorization of services for beneficiaries, and payments to providers, in order to increase profits." The report recommends that CMS enhance its oversight of Medicare Advantage plans and address persistent problems related to inappropriate denials and insufficient denial letters.