Ask the payment expert: Why are our Medicare Advantage claims being denied?

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Ask the payment expert
Ask the payment expert

Why are we having denials in Medicare Advantage claims even when they authorized resident coverage?

This has been happening all over the country. The Centers for Medicare & Medicaid Services established a new procedure this year for dealing with Private Fee for Service Medicare Advantage Plan (PFFS) and provider billing issues. A facility must file an appeal with the PFFS. If the facility has an unfavorable appeal with the Medicare Advantage Plan, this new service will provide an expedited approach to billing issues.

You should review the Medicare Advantage appeal process and follow that process. If you do not receive a timely response, try this new process.

You can locate the appeal and grievance procedures for Medicare Advantage at the CMS Web site.

The Medicare Advantage appeal process is very similar to the Medicare A appeal process. Most of your insurance companies also will have this information on their Web site. Before you take a Medicare Advantage patient, you need to make sure your staff reviews the information so you know your rights.

Another issue that has been identified is that many facilities are taking Medicare Advantage residents without a contract. This puts the facility at increased risk of denials.

If you do not have a contract, your reimbursement is being managed by the Medicare Advantage program and not you. The best reimbursement is based on the RUGs levels.

Medicare Advantage processes must also follow Medicare rules. That means that the coverage criteria are the same.

Do not think you can keep a Medicare Advantage recipient on coverage if you wouldn't keep the same resident on coverage with Medicare A.

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