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Medicare Advantage Denials

The Medicare Advantage (MA) program allows Medicare beneficiaries to receive benefits through private plans rather than the traditional fee-for-service (FFS) program. MAplans carry many of the same billing and service requirements as commercial or managed care plans, including, lack of medical necessity and/or authorization, timely filing and unique coding procedures.  The hybrid nature of the program, combining commercial insurance practices and Medicare regulations, presents a unique set of challenges.  MA plans can use selective contracting and utilization management to coordinate and manage care and control service use. Some plans offer a uniform benefit package and premium across a designated region while others vary their premiums and benefits across counties.  In order to be properly prepared for a host of different denials, a facility must be well-versed in all possible and applicable regulations or requirements and must maintain a wealth of resources available to combat the denials issued to receive proper compensation for the services rendered.

Contracted Providers

The MA landscape shifts dramatically if a provider is contracted – “in-network” – with an insurer. Being contracted means being more accessible for plan enrollees, but it also generally means having more limited appeal rights and no right to independent review. With fewer opportunities to make their case, contracted providers need to maximize the value of each appeal opportunity.  Washington & West’s experience and integrated legal, clinical, and coding approach can do just that.

 Non-contracted Providers

Providers who are not contracted have a right to ask a person without a financial stake in the outcome to decide whether or not a claim should be paid, but that is not enough to guarantee a favorable result and reimbursement. An independent review may mean little if providers do not appeal their denied or underpaid claims effectively, a process that requires integrated advocacy which extends well beyond the submission of medical records. If still unsatisfied with the independent review, non-contracted providers can request an Administrative Law Judge or the Medicare Appeals Council to review and decide their claim; opportunities that demand advanced knowledge and skilled advocacy.


One of the principles behind MA is that plans could save Medicare money by reducing utilization before services are rendered, in contrast to Medicare’s familiar “pay-and-chase” model. However, many plans also have robust audit programs that search for claims to deny months or years after payment, some of them subcontracting with Medicare Recovery Audit Contractors (RACs). Appealing the denials these audits produce requires expertise in analyzing a medical record and developing a cogent, persuasive argument, expertise Washington & West has developed across years of practice and thousands of appeals and Administrative Law Judge hearings.

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Towson, MD 21204
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