A Medicare Advantage Problem That Can Cost You

If you, or a parent, or just someone you care about is enrolled in a Medicare Advantage plan, you need to be aware of a glitch that can cost you plenty if you’re not persistent.

Unlike Original Medicare, Medicare Advantage (MA) plans typically require getting prior authorization for medical care. A major survey by the non-profit Kaiser Family Foundation reports that more than 2 million out of over 35 million prior authorization requests were fully or partially denied.

That’s “only” six percent or so, but just to be clear that’s the average among major insurance companies running MA plans. A few individual insurers denied more than 10% of prior authorization requests.

Now here’s the most important point: When enrollees (or their medical providers) appealed a denial, it was overturned fully or partially more than 8 out of 10 times. Let that sink in— people who took the time to push back and challenge, “won” more than 80% of the time. That sure seems like the profit-focused insurance companies are playing some sort of game where they are hoping folks will just walk away or pay for something out-of-pocket. But when an enrollee appeals a denial, the insurer much more often than not agrees to cover the procedure. 

Insurers are rewarded for that strategy. The same survey found that just 11% of denied prior authorizations were challenged. Let’s flip that— 89% of enrollees who weren’t granted a prior authorization didn’t push back.

Look, I wish this wasn’t the way MA worked. The fact that more than 80% of denials were reversed in 2021 sure seems to signal that the system is broken. And the cost to medical offices that do challenge denials is another unnecessary drain on a part of our healthcare system that is already stretched thin. But this is where we are at. 

If you or someone you know is enrolled in MA and is told a pre-authorization request has been denied, the takeaway is to push back and file an official appeal.

You should receive a Notice of Denial of Medical Coverage from the insurer. That form should include directions on how to appeal. If not, contact the insurer and ask for instructions on how to proceed. You may be able to do it over the phone, but more likely you will need to submit some paperwork. You have 60 days to file your appeal, and the insurer has 30 days to respond. You can also ask for an “expedited” decision if you have a pressing medical need. And it can help your case if your care provider chimes in with a letter stating why the procedure is necessary.