If you’re a frustrated Medicare Advantage enrollee facing more claim denials, you’re one of millions more consumers in the same sit✤uation. Fortunately, there are ways to take actiꦉon. 

A 2024 report from KFF found Medicare Advantage insurers fully or partially denied 7.4% (3.4 million) of claims submitted for health care pre-authorization in 2022, a sharp jump up from 5.8% in 2021 and 5.6% in 2020. 

Medicare Advantage companies use 澳洲幸运5官方开奖结果体彩网:prior authorization to lower their claim-payment costs by managing how services are used, often re𝓀quiring the process for certain services, medical items, inpatient care, or ওmedications. 

Unfortunately, delays in the prior authorization process can lead to negative health impacts. A 2024 American Medical Association (AMA) survey found that 78% of physicians said the prior authorization process can sometimes lead to patients abandoning the recommended treatment altogether.

The AMA, all 50 state medical associations, and numerous healthcare⛎ institutions are expressing concern about the climbing rate of MA denials. There’s also increasing bipartisan Congressional scrutiny and support for speeding up Medicare Advantage claim reviews, modernizing the process, and increasing transparency in requireme🐻nts. 

For example, in November 2024, 135 Democrats and 86 Republicans co-sponsored legislation to improve the prior authorization process. A similar Senate bill had already drawn 54 co-sponsors from both parties. 

In the meantime, when your prior authorization or claim for past service is denied, it may seem like your only options are to pay 澳洲幸运5官方开奖结果体彩网:out of pocket for the service or claim, work out an arrangement𝓰 with the p🐼rovider, or go without the care. 

However, you can—and should—fight back against denials. The odds are in your favor, too: KFF found that while only about 10% of MA deniඣals were appealed in 2022, a staggering 83% of those appeals were successful, indicating they may have been initially denied in error. 

How to Contest a Medicareꦯ Advantage Claim Denial

1. Review the Denial

Medicare Advantage plans are required to send denials in writing, and🔯 denials are usually explained as “not approved” or “not covered.” You also may receive a verbal denial first, followed by a written letter.    

Medicare Advantage plans usually won’t require prior authorization for preventive care, but you may need it—and you could be denied coverage for:🤡

• A specific service (such as surgery), supply, or medication 
• A health care service, supply, or medication you’ve already received
• Continuing a service or other care you’re receiving now
• Supplemental benefits provided by your plan, not Medicare 

“The more expensive you become, the more opportunities the plan will have to require prior authorization or issue denials,” said Tatiana Fassieux, education and training specialist for Medicare policy, advocacy, and training at Californiꦫa H🅠ealth Advocates. 

For example, 澳洲幸运5官方开奖结果体彩网:Ozempic may🧔 only be covered by your MA plan if your need fits neatly within FDA indications, such as Type 2 diabetes. However, your plan might impose other restrictions, too, like only covering Ozempic for one year or only covering Ozempic after you’ve tried other medicationsಞ. 

A denial might also occur because the medical biller didn’t add the right evidence for the procedure. For example, eye lift surgery coverage might require a surgeon's photos of the eye. 

2. Review Your Plan’s Appeal Rights 

In the initial Medicare Advantage denial letter, your plan will tell you how to appeal. In general, there are five levels of appeals for an MA decision, also known as an "organization determination.”

“Iꦅt’s a formal process,” Fassieux said, and you need to follow the steps described. “It’s important to follow through and not just accept the first denial.”

You can review your Medicare Advantage plan's specific appeal rights and rules in the “Evidence of Coverage” on your insurer’s website, typically as a PDF. Also take note of the timelines for each step of the appeal process. There may also be guidance on how best to appeal, particularly for prior authorizations that need to happen quickly. 

If time is of ♋the essence for health and safety reasons, your insurer might state a “fast appeal” typically happens through a phone call or in writing. More standard timeline appeals are made in writing. 

Appeal Level 1: Reconsideration From Your Plan

Level 1⛄ appeals are called “Health Plan🥂 Reconsiderations” by your plan provider. 

If you file an appeal, the plan will inform you ofﷺ its decision within 30 days if yo𓃲u requested a service and 60 days if you requested a payment. 

If the plan doesn’t decide in your favor or doesn’t respond, your appeal automatically forwards to Level 2, which involves an organization outside your insuranc🐓e company. 

You can also request an immediate decision review if you receive services in some facilities, such as an inpatient hospital admission (typically covered under Medicare Part A) or skilled nursing facility, and t👍he plan decides to disc🗹harge you.  

Appeal Level 2: Independent Review Entity (IRE)

At this level, your appeal is a📖utomatically sent to an outside organization for review. The appeal process timeline depends on which service was involved:

• Preauthorization appeal: 30 days
• Payment appeal: 60 days
• Part B drugs: 7 days
• Fast appeal: 72 hours

In some cases, your plan can extend the appeals deadline by 14 days if it provides notification and reason, such as needing more information t🅷o decide. You’ll also be informed regarding your rights if you disagree with the extension decision. 

If the Independent Review Entity thinks your life or health is at ri♏sk due to waiting, you’ll fall under “🦂fast appeal.” 

If the outside organization also denies your appeal, you have 60 days from th🅰e decision date to ask for a Level 3 appeal.

Appeal Levels 3 to 5 

If you disagree with the Level 2 decision, you can appeal at highဣer levels, but the dollar amount in content😼ion will dictate how far your appeal can go. Your plan can appeal the outcome as well.

3. Craft Your Claim Denial Appeal

When it comes time to craft your appeal, you’ll typically work🐼 with your doctor. Appeal paperwork is available through your Medicare Advantage insurance company and will likely include requests for the fol♈lowing: 

• Your personal information 
• Your description of the issue
• Medical history and treatment recommendations 
• Results you hope to get from the insurance company

You may also want to incluꦛde details about your: 

• Medical history
• Diagnostic test results
• Specialist recommendations
• Treatment plans
• Detailed clinical notes 

It’s also recommended you provide an explanation about the medical necessity of what you need or have already received and paid for. Be ready to negotiate w෴ith various entities to find a resol💧ution that works.

Keep detailed records of all communications, including notes on the date, time, who you spoke with, 𝓡and what was said. 

Another Option: Choose a New Plan 

If you feel your plan puts you in too many difficult positions regarding denials, take advantage of the annual January 1-March 31 Medicare Advantage open enrollment period. 

Review the “Evidence of Coverage” when considering a Medicare Advantage plan to judge the language used around appeals. Research plans to determine which services and medications ꦑcould require prior authorization in 2025.🐻 Speak with your local State Health Insurance Assistance Program (SHIP) for more advice. 

Also, be skeptical of marketing that advertises inexpensive generic-tier medications—they won't do you much good if your medication isn’t covered or you have to undergo a complex process to get it. 

Fassieux suggested that with Medicare Advantage and Part D, look past the zero-premium marketing and maxim💎u🐷m out-of-pocket amounts. Instead, review all plan elements.  

“We’re entering a time now in healthcare where the right coverage isn’t a given,” Fassieux said. “Think about it, and be careful and judicious in your plan choice.”