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New Video: Inspector General Report on Medicare Advantage Claims Denied

Investigation Into Medicare Advantage Claim Denials

The OIG of HHS Investigation is Quite Revealing

The Office of Inspector General for HHS has concluded an investigation into Medicare Advantage companies and the extent to which claims are routinely denied.

It is sad to see that claim and procedure denials are so commonplace.”
— Christopher L. Westfall, Sr. RFC®
CHARLESTON, SC, UNITED STATES, October 31, 2018 / -- The Senior Savings Network has released a video summarization of the shocking, recently-released OIG report on Medicare Advantage claim denials. The video highlights the report's findings which include the fact that 75% of appeals of denied claims ultimately resulted in the member's claim denial being reversed. Even more revealing in the report was the fact that 99% of denied claims are never appealed by the member. The OIG report is titled, "Medicare Advantage Appeal Outcomes and Audit Findings Raise Concerns About Service and Payment Denials" and can be found here:

The Senior Savings Network, an independent group of insurance agents who specialize in Medicare insurance for seniors across the United States, has released the video in an effort to shine a light on the OIG report, which was released without fanfare on the Health and Human Services website. Christopher L. Westfall, Sr. RFC®, owner of the Senior Savings Network and member of the Forbes Finance Council, says about the report, "It is sad to see that claim and procedure denials are so commonplace, and yet seniors on Medicare Advantage plans seldom know the information needed to submit an appeal which, as this report shows, would have overturned the denial in over 70% of the cases."

In the video, the quote from the OIG report that is perhaps most troubling points to the possible motive of such routine denials, "A central concern about the capitated model used in Medicare Advantage (also known as Medicare Part C) is the potential incentive for insurers to inappropriately deny access to services and payment in an attempt to increase their profits."

Medicare Advantage has been an increasingly popular alternative to original Medicare for seniors turning 65 and making the choice between Medicare-related coverage. Medicare Advantage plans are paid a monthly payment by Medicare in order to manage the care for its senior members, thus relieving Medicare of many variable risks associated with the fee-for-service model of the original Medicare. The alternative to this form of managed care involves having original Medicare along with a Medicare Supplement plan which pays most of the costs that original Medicare does not pay.

While the Senior Savings Network assists seniors considering their Medicare options and provides both Medicare Advantage and original Medicare with Medicare Supplement, it is critical that seniors considering their options also factor in their access to care. Seniors considering Medicare Advantage already understand that, in most cases, they must utilize a contracted network of providers, pay co-payments and other costs, but seldom understand the pre-approval and "managed" component to their care. As the OIG report stated, "Under managed care, MAO's (Advantage plans) need to balance managing healthcare costs and utilization while ensuring beneficiary access to quality care."

Christopher Westfall's videos on Medicare trends have garnered over 1.7 million views on Youtube and he is considered a thought leader in the Medicare agent community. In addition to the Senior Savings Network agency, he also runs a training service for insurance agents in the Medicare field,

Christopher L. Westfall, Sr. RFC®
Senior Savings Network
+1 800-729-9590
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Medicare Advantage Investigation by OIG

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