Seniors who choose a private Medicare insurance plan shouldn’t hesitate to resist pre-approval denials, according to new research.
Of the 35 million requests by Medicare Advantage participants for preapproval of medical services or drugs in 2021, 2 million will be denied in full or in part, according to the FDA. New analysis From the Kaiser Family Foundation (KFF), a non-profit organization.
However, in 11% of cases contested, insurers reversed more than four-fifths (82%) of the original decision, according to the report.
The results show that the approval process can create unnecessary obstacles for patients to get medical care, and seniors are choosing to shop for these popular plans to avoid these hassles. It emphasizes that you may want to spend more time.
Jeannie Fuglesten Biniek, KFF’s Associate Director of the Medicare Policy Program and Nolan Sroczynski, KFF’s Data Analyst, said, “The higher frequency of favorable outcomes on appeal means that more decisions are made in the first place. The question arises as to whether the part should have been approved.
“It may reflect an initial request for failure to provide the necessary documentation. Delays were possible due to additional steps to challenge the initial pre-approval decision, which could have adverse consequences.
don’t answer no
Preapproved hoops primarily affect people enrolled in the Medicare Advantage Plan, a privatized managed-care version of the traditional Medicare program.
In 2022, nearly all Medicare Advantage participants (99%) had plans that required preapproval for some services. A KFF study that examined data from 515 Medicare Advantage contracts representing 23 million Medicare Advantage participants found that most commonly, more expensive services such as chemotherapy and stays in skilled nursing Prior approval is required.
Pre-approval of insurance coverage has been around for a long time. This is a way insurance companies keep costs down by screening people to make sure they aren’t being prescribed procedures or services that aren’t medically necessary.
“Insurers use pre-approval differently,” Biniek told Yahoo Finance. “I was surprised by the amount of variability between plans and between insurers.”
For example, rejection rates ranged from 3% for Anthem and Humana to 12% for CVS (Aetna) and Kaiser Permanente. The percentage of denials appealed was almost double the average (11%) for CVS (20%) and Cigna (19%). On the other hand, a much smaller percentage (1%) of Kaiser Permanente’s denials are appealed.
For clarity, some of these procedures and services (380,000) that were approved when patients objected were only partially covered. treatment sessions may have been included, but only 5 were approved.
Still, “people who have gone through that appeal process are often successful,” Biniek says. We may have a better chance of getting some of our requests finally approved.”
Medicare Advantage vs Traditional Medicare
Traditional Medicare rarely requires preapproval for health care services or medications, but the big draw for Medicare Advantage Plans is that they offer benefits not included in traditional Medicare, such as eyeglasses, dental insurance, and fitness classes. It is usually covered.
According to The Commonwealth Fund’s 2022 Biennial Health Insurance, nearly one in four Medicare beneficiaries enrolled in a Medicare Advantage plan (24%) cite additional benefits when choosing a plan. investigation Of 1,605 adults enrolled in Medicare. And one in five (20%) of them cite copayment limits as a primary reason for their choice.
“This is one of the big trade-offs people make when choosing Medicare Advantage,” Biniek said.
But many do. Last year, nearly half (48%) of eligible Medicare beneficiaries, or 28.4 million of his 58.6 million Medicare beneficiaries overall, were enrolled in Medicare Advantage plans.
Medicare Advantage shoppers should ask about preapproval policies
Therefore, one way to prevent the hassle of challenging a denied preapproval is to research their requirements in various Medicare Advantage plans when seniors are about to sign up.
As part of its oversight of Medicare Advantage plans, the Centers for Medicare and Medicaid Services (CMS) ask these insurers for each Medicare Advantage policy how many previous approval decisions and , are requesting to submit data, including whether the request was approved. Insurers must also indicate the number of initial decisions that have been appealed and the outcome of that process.
“The Kaiser report did not include reasons for denials, but other studies show that missing documents and errors in medical coding are common,” said a Medicare and Social Security expert. is home,get yours” A series of books on Social Security, Medicare and Health Care told Yahoo Finance.
Reasons why the report doesn’t cover denial details: Medicare Advantage insurers may be unable to provide coverage because services were not deemed medically necessary, insufficient documentation was provided, or other reasons, according to the researchers. requirements were not met.
“If it’s denied, they have to tell the patient why,” Biniek said. It is worth making sure that you understand the
The good news is that the Biden administration recommended changes to the approval process. CMS released two of his regulations in December, which he called for to revamp the electronic processes used by Medicare Advantage Plans to approve medical services and prescriptions.
the provisions of First Proposed Rule It is intended to improve the use of electronic preapproval processes and to improve decision-making speed and transparency, and applies to Medicare Advantage and certain other insurers.of Second Proposed Rule Clarify the criteria that Medicare Advantage Plans can use in setting prior approval policies and the length of time prior approvals are valid.
“Looking ahead, Medicare Advantage insurers have received notices from CMS and Congress to significantly improve their previous approval process,” said Moeller. “Thus things can turn around, but of course it is of little consolation for those who have been unjustly denied care. The message here is that appeals work, People should challenge adverse rulings more often.”
Kerry is a senior reporter and columnist at Yahoo Finance. follow her on her twitter @Kelly Hannon.
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