OIG report ‘exposes’ Medicare Advantage

YARMOUTH, Maine – The OIG’s recent finding that some Medicare Advantage plans are delaying or denying access to services shines a light on “one of the most financially damaging things happening to HME providers right now,” says Dan Fedor. 

“It’s really ugly what’s happening,” said Fedor, director of reimbursement and education for U.S. Rehab, a division of the VGM Group, who has been known to call Medicare Advantage “Medicare Disadvantage.” 

Here’s what Fedor had to say about why the OIG report came as no surprise and how some Medicare Advantage plans are getting away with covering fewer services and imposing additional requirements than traditional Medicare. 

HME News: Why weren’t you surprised by this report? 

Dan Fedor: We’ve known this in the HME industry for years. I’m really happy to see the report. I’m not happy that this is something that providers have to deal with, but at least the report exposes what we’ve all known for years. We’ve been complaining about this to CMS and our congressional members. 

HME: How will the report take those complaints to another level? 

Fedor: Hopefully, it will shine a bigger light on the issue. 

HME: What can providers do to advance the case against Medicare Advantage plans that are covering fewer services? 

Fedor: The answer is to keep track of these issues as they happen. CMS, Congress – they’re always going to say, “Show me proof.” I just had a provider send me an example of an ALS patient who was denied a Group 3 power wheelchair because the plan thought their condition didn’t warrant it and they might benefit from a simpler wheelchair. That’s the word they used, “simpler.” 

HME: Is this an exception, not the norm? 

Fedor: This is the vicious cycle we see: If a provider is denied a prior authorization, there’s a delay in the patient receiving the product and the provider getting paid; if a provider is approved, the patient gets the product but the provider is still delayed in getting paid. It gets to the point where the provider doesn’t have the resources to fight and gives up.