MA plans fall short of responsibilities, say respondents

YARMOUTH, Maine – Medicare Advantage plans are routinely delaying or denying coverage for products and services that meet Medicare guidelines, say 88% of respondents to a recent HME Newspoll. 

“Medicare Advantage organizations don’t seem to fully understand Medicare coverage criteria,” wrote one respondent. “We routinely get denied for items that would easily pass audit scrutiny with traditional Medicare. It is extremely frustrating as a provider to work with physicians to document in the manner specified by Medicare, just to get denied by the Medicare Advantage organizations.” 

Medicare Advantage plans are required to cover the same services as original Medicare and not to impose additional requirements that are more restrictive than original Medicare’s national and local coverage policies. 

But respondents say some plans are imposing far more restrictive requirements. 

“I had a patient needing NIV for hospital discharge,” wrote one respondent. “Her discharge was delayed two days and I finally had to get my congressman involved. Cigna was asking for an electrical inspection before they would (authorize it).” 

Both delays and denials have increased in the past year, say 75% of respondents, or remained steady, say 22% of respondents. 

“They typically act a lot like Medicare with few exceptions,” said one respondent. “However, when they don’t, claim denials are almost impossible to fix because there are no solid explanations.” 

And while HME providers are no strangers to audits, some Medicare Advantage plans take it to a new level, say respondents. 

“UnitedHealthcare is auditing every Medicare Advantage claim that meets the LCD,” wrote one respondent. “They deny 90% on appeal. They even audit Medicare primary paid claims that cross over to UHC.”  

While Medicare Advantage plans have exploded in popularity in recent years, some poll respondents say they may have to reconsider accepting them. 

“It has gotten to the point where I’m only going to accept Medicare, as I have lost tens of thousands of dollars from HMOs for non-payment,” wrote one respondent.