Office of Inspector General Says Medicare Advantage Organizations are Denying Services Inappropriately

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Jul 21st, 2020

We attended the recent virtual RISE National Conference and had the opportunity to listen to presenters share their knowledge about risk adjustment and HCC reporting and data validation. Among the presenters were representatives from the Office of Inspector General (OIG), who presented findings from encounter data from 2012-2016. They began by stating their desired outcomes, which include healthier beneficiaries, lower costs, better care, and a more efficient system and that the three main areas for concern include:

1. Quality services (network adequacy, denials, and appeals)
2. Federal funding (fraud, risk adjustment validation audits (RADV), and rates)
3. Data integrity (security, adequacy, and compliance)

The OIG is the federal policing agency which identifies criminals committing fraud in an effort to reduce beneficiary harm and fraudulent behavior that leads to increased tax burden on the population. According to them, although only 1% of denials by Medicare Advantage Organizations (MAOs) were appealed, 75% of those were overturned on appeal. This begs the question, why are providers and beneficiaries not appealing more denied requests for covered services?

Asking the following questions may shed some light:

1. Does the MAO provide a benefits coordinator that can interact with the beneficiary to ensure they understand their medical benefits?

Providing the beneficiary with an explanation of their benefits in a manner they can understand (layman’s terms) helps not only the beneficiary by ensuring they obtain the care and education that may help them improve their risk scores, but will also assist the payer in helping the beneficiary see the value behind wellness checks to ensure they are receiving the best available care and information about their health.

2. Does the MAO provide beneficiary representation to the provider organization?

Providers caring for the beneficiaries will verify benefits when they are needed for the services being rendered; however, they may not be aware of additional benefits that promote prevention, wellness, and patient education. Providers want their patients to be healthy and when they are empowered with knowledge about the benefits available to them for wellness visits, vaccines, and more, they can encourage patients to invest in their own health and identify the tools the MAO offers to assist them in accomplishing that goal.

3. Does your MAO encourage provider groups to appeal service and claim denials? Is the process straightforward or is it cumbersome to discourage appeals?

If MAO benefits are being wrongfully denied, and the process of appeals is cumbersome and difficult, the welfare and health of the beneficiary are not being put first.

As a result of the study, the OIG recommended MAOs take the following actions:

• Implement enhanced oversight of MAO contracts to ensure denials are valid
• Address inappropriate denials
• Provide beneficiaries with clear information

As an MAO, now is the time to begin looking into how you can facilitate education on the benefits available to beneficiaries and the options available to appeal a denial for services. The information available through the OIG is an excellent place to begin. 

About Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Aimee L. Wilcox is a medical coding, billing, and auditing consultant, author, and educator with more than 30 years of clinical and administrative experience in healthcare, coding, billing, and auditing. Medicine, including coding and billing, is a constantly changing field full of challenges and learning and she loves both. Aimee believes there are talented medical professionals who, with proper training and excellent information, can continue to practice the art of healing while feeling secure in their billing and reimbursement for such care.