tci Medicare Compliance & Reimbursement - 2018 Issue 14

Industry Notes: OIG Plans to Target MA Claims

Are you seeing an uptick in your Medicare Advantage (MA) denials? This might be the reason. The HHS Office of Inspector General (OIG) added a topic to its Work Plan last month noting that the capitated payment model Medicare Advantage uses may incentivize payers “to inappropriately deny access to, or reimbursement for, health care services in an attempt to increase profits for managed care plans.” Therefore, the OIG is reviewing records to determine whether some MA preauthorizations or claims are being denied, despite being medically necessary. “To the extent possible, we will determine the reasons for...

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