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Medicare Insurance Denials – What Can You Do?

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Medicare Advantage policyholders have their claims denied at an outrageous rate, according to the federal government’s own reporting. On the bright side (sort of), claimants who appeal their denials are by and large successful in eventually getting their claims approved. If you’ve had your legitimate Medicare Advantage insurance claim denied, there are steps you can take to get the coverage you need and are entitled to, and you might also have a right to monetary damages based on your insurer’s violation of the law.

Medicare Advantage insurers deny a disproportionate number of claims, report finds

Medicare Advantage plans are a combination of government-issued Medicare benefits with those offered by a private insurer, usually covering services such as prescription drugs, dental care, and vision care. Many seniors and others eligible for Medicare coverage choose to purchase Medicare Advantage plans to supplement their coverage; about 21 million people were enrolled in Medicare Advantage plans in 2018, which accounts for roughly a third of all Medicare beneficiaries.

A federal Department of Health and Human Services report released in 2018 revealed alarming statistics on the rate of improper Medicare Advantage claim denials. The report found “widespread and persistent problems” regarding denials of patient care and payment of claims among Medicare Advantage insurance plan providers. The report revealed that, among those who appealed their claim’s denial, about 75% were successful at the first level of the appeals process. Sadly, only 1% of all those who receive denied claims appeal those denials, on average.

Even the denials themselves were often unclear or riddled with errors, making it difficult for patients with denied claims to understand the status of their claim and appeal a denial. According to a report by the Inspector General of the Centers for Medicare and Medicaid Services, a whopping 45% of all denial letters sent by Advantage plans contained information that was incorrect or incomplete. These confusing denials make it even more of a challenge for sick, frail, or elderly patients to fight for the benefits they deserve. If you or your parents are in this situation, an experienced insurance bad faith lawyer will likely be willing to evaluate your claim denial for free and let you know what options you might have at your disposal.

Denials hurt patients and medical service providers

Not only do denials hurt patients who need the services they request, but they also hurt providers. Medical service providers who have their claims for reimbursement denied are statistically less likely to continue offering those services. This can cause serious harm to Medicare members who are strictly limited to Medicare’s network of physicians when choosing a service provider.

Medicare insurance claim denials can cause grave harm to a patient who needs treatment for a serious illness, as well as additional strain and anxiety that can have detrimental effects on recovery for someone struggling to survive. If you’ve had a Medicare Advantage insurance claim denied, it’s important to know that you may be able to appeal the denial and recover the benefits due as well as compensation for any additional harm you’ve suffered. Contact an insurance law attorney to review your denial and advise you accordingly.

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