IBM Medicare Advantage Appeals Process for Claim and Pre-Authorization Denials

 If you decided to enroll in the IBM UHC Medicare there is a much higher probability (than in Original Medicare) that your plan will deny coverage for pre-approvals or for treatment you received.  I've written extensively about why it is done.  In this post, I will describe what to do when it happens.  

There are lots of reasons why MA plans deny claims for treatment such as being medically unnecessary, requiring a referral from your primary care doctor or requiring pre-approval for the procedure.  In most situations, you will be able to reverse the denial so that the MA plan will have to allow the treatment or pay the claim.  The claims that have the lowest chance of being reversed are denial claims related to procedures Original Medicare does not cover such as dental or vision treatments.  An MA plan cannot hold you accountable for not having a pre-approval or a pre-authorization if the doctor treated you.  It is up to the doctor to know to not treat you. 

The most important sentence to remember in this post:  

A PHONE CALL TO THE PLAN IS NOT A FORMAL MEDICARE APPEAL.  

The only way it is a FORMAL MEDICARE APPEAL is if it is done it in writing and sent to the request for reconsideration address provided by your plan in their denial letter (it is an "Explanation of Benefits" or "EOB" letter).  

The claim denial appeals process is defined by the federal government, not by your plan.  There are also levels of appeal which allow you to appeal to different levels of authority.  You cannot go to the next level of appeal unless the lower level denied the claim:

1. Appeal level 1 is a review done by the Medicare Advantage plan.  If they deny a second time then
2. Appeal level 2 is a review done by an independent review board (they are called "Maximus").  This is an independent group who work for the federal government Medicare agency. If they deny and the cost of the claim is at least $180 then
3. Appeal level 3 is done by an administrative law judge (ALJ) and is a phone call between you and the assigned litigator. You do not need to have a lawyer to request this appeal.  Medicare now refers to this level as the "OMHA" level of appeal (Office of Medicare Hearings and Appeals) but you will see documentation that uses "ALJ".  If the ALJ rules in your favor, you still might have to go to your state attorney general to get the MA plan to pay the claim.  If the ALJ denies and the claim is at least $1,850 then
4. Appeal level 4 is to the Federal District Court.  It is recommended you get a lawyer for this level.

The MA plan will throw some gibberish into a claim denial letter about having "60 days" to do a appeal.  The truth is, if you have a good reason why it took longer to appeal (like you were in the hospital) and you explain it in writing in your request for appeal, you can do the appeal.  

Appeals are not all that easy to do and you will need supporting information from your provider, but don't be intimidated by it!  MA plans expect you to be intimidated.  Disappoint them!

If you need help to do this, every state has an agency know as the State Health Insurance Assistance Program (SHIP).  Call and ask for help.  You can find your agency at this website:

https://www.shiphelp.org/local-medicare-help?utm_source=google&utm_medium=cpc&utm_campaign=220228-Search&gclid=Cj0KCQiAzeSdBhC4ARIsACj36uGCGk_z2oOk48Y5LOUFEibAVGzDIlfGWIZjjxzDcVR5479jMnRrpvQaAlyeEALw_wcB

Updated 1/9/2023:

Medicare Advantage will deny:

https://www.statnews.com/2022/11/15/replace-medicare-advantage-failure-with-medicare-part-f/

https://www.medpagetoday.com/special-reports/features/102966

Updated 2/27/2023:

Congress is proposing rule changes to try to rein in the antics of Medicare Advantage plans.  If nothing else (and it is highly likely nothing happens), this is a good summary of the problems with Medicare Advantage plans:

https://jayapal.house.gov/2023/02/16/jayapal-delauro-schakowsky-lead-effort-to-reform-medicare-advantage/

Updated 3/6/2023:

More about how MA plans deny.  This is about hospital inpatient stays not being "medically necessary".  Maybe it isn't if the patient is young, but the older you are, the more likely something "goes wrong".  Doctors, rightly, want to be sure it doesn't.  MA plan make money so they deny:

https://www.marketwatch.com/press-release/medicare-advantage-plans-deny-more-inpatient-level-of-care-claims-than-all-other-payor-types-2023-02-15

Updated 3/23/23

This is about the complexity of dealing with and health impact of prior authorization denials:

https://wusfnews.wusf.usf.edu/health-news-florida/2023-03-18/feds-move-to-rein-in-prior-authorization-a-system-that-harms-and-frustrates-patients