Medicare Advantage: Industry fights back

WATERLOO, Iowa – There’s a renewed call to submit data that demonstrates Medicare Advantage plans are wrongly denying coverage for home medical equipment, and during a panel at the VGM Group’s Heartland Conference on June 11, stakeholders shared a prime example. 

Stakeholders have been encouraging providers, where applicable, to submit claims through the prior authorization process for traditional Medicare, even for Medicare Advantage patients. If Medicare approves the claim and Medicare Advantage denies it, this gives providers “ammunition,” said Dan Fedor, director of reimbursement and education for U.S. Rehab, a division of VGM. 

“If Medicare has prior authorization for a product, submit it,” he said. “That way you have that ammunition. If (Medicare Advantage) rejects it, you have a strong case at that point.” 

A VGM member followed that advice and recently received the following response from a Medicare Advantage plan, which Fedor shared during the session: 

“It appears that you are filing these to Medicare FFS first to see how CMS will determine outcome. That should not be part of the process. Our reviewers do not have any line of sight into CMS FFS process. We do not manage our patients completely through CMS. We have our own policies and procedures that you, as a contracted provider, are required to follow. It is unreasonable to expect that since you have CMS FFS approval – that we should match that. Again, that is impractical to make that assumption.” 

Fedor, as well as Craig Douglas, vice president of payer and member relations for VGM, and Ronda Buhrmester, senior director of payer relations for VGM, pointed out that’s exactly what Medicare Advantage plans are supposed to do – follow Medicare coverage. 

“MA organizations must cover all Part A and Part B benefits, excluding hospice services and the cost of kidney acquisition for transplants, on the same conditions that items and services are furnished for traditional Medicare,” Douglas said, referring to CMS language. 

Stakeholders like VGM and AAHomecare have discussed this disconnect with CMS and after sharing some initial data backing it up, the agency has asked for more data, Douglas said. Providers can submit data on these types of denials here. 

Kim Cuce’, director of business optimization for VGM, says providers can set up processes in their software to flag when these types of denials take place, making it easier to share data. 

“At the end of the month, when you need those (results for the survey), just run that ad hoc report,” she said. 

The panel also encouraged providers to alert their local media about these types of denials and to be straight with their patients about who is the bad guy. 

“Tell them: ‘It’s your insurance; not us,’” he said.