Many seniors opt for private Medicare Advantage plans instead of traditional fee-for-service Medicare so they can access a broader array of services and perks such as gym memberships. By federal law, insurers that provide this privatized alternative must cover everything that traditional Medicare covers. Problem: A report by the Inspector General of the US Department of Health and Human Services uncovered a pattern of incorrect service denials by Medicare Advantage insurers. In fact, 18% of cases where payment was denied and 13% of cases where prior authorizations were denied should have been approved.
When such denials are appealed, the insurers sometimes reverse themselves and approve the payments—that was the case for 3% of denied authorizations and 6% of denied payments. Unfortunately, even when the patient “wins,” a denial followed by an appeal eats up precious time, delaying treatments. And too few seniors bother with the appeals process—they just pay out of pocket or go untreated.
What to do: Once a year, take stock of your health-care finances, and reassess the plan you’re on. Do an annual “health-care audit,” in which you ask yourself whether your plan fits your needs…your providers will still be in network next year…you need to stay on all your medications…and so on. As you conduct your analysis, stay aware of enrollment deadlines.
No matter what plan you’re on, never pay a medical bill until you’ve reviewed the insurance provider’s explanation of benefits. If you believe you’ve been wrongly denied, call the insurance company. Sometimes that’s all that’s needed. But if not, file a formal appeal.
