Medicare Advantage: Task force readies to intervene 

WASHINGTON – A task force led by NCART has built a systematic process for collecting data on Medicare Advantage denials so stakeholders can show CMS that these plans are not following the rules. 

“These denials are not a fluke; they are not anecdotal,” said Wayne Grau, executive director of NCART. “If it were just one mistake, it could be passed off, but what we’re seeing is prevalent. They’re not abiding by Medicare guidelines, and they’re supposed to be.” 

The task force is now asking providers to fill out a contact form to indicate their interest in participating in the process. 

A group of research students led by Cara Masselink, executive director of the Clinician Task Force and an associate professor at Western Michigan University, will provide participating providers with a template they can use to submit information on denials on a monthly basis. 

“Everything is confidential from the supplier standpoint,” she said. “We’re asking for information like diagnosis and codes submitted, but mostly we’re asking for the reason for the denials, so we can identify gaps and patterns in what is happening and use that information to support intervention.” 

The task force is also asking providers to simultaneously process their power wheelchair claims not only through Medicare Advantage but also Medicare’s prior authorization program to help determine where and how denials are occurring. 

“What we’re finding a lot of the times is that the files are actually approved for medical necessity through traditional Medicare, but the same files submitted the same way to Medicare Advantage are getting denied,” said Tugba Koca, a corporate training manager for ACU-Serve. “It’s a big problem. It’s causing administrative burden on the supplier and causing delays and access to care issues for the patients.” 

The Medicare Advantage denials that clinicians like Amber Ward receive are hard to grapple with. She is a member of the CTF and an occupational therapist at Carolinas Healthcare System who works with people with progressive neurological conditions like ALS. 

“It’s true suffering,” she said. “That’s a strong word but when you have clients with progressive disorders and you add on the months that it takes to go back and forth (to approve a claim), it’s true suffering. We’ve seen increases in pressure injuries. We’ve seen they’re bed bound longer.” 

Ultimately, the task force plans to share data with CMS, pull in organizations like the ALS Society and develop resources that can be used to increase advocacy. 

“But it all starts with the data,” Grau said.