From Dr. Tom's Desk
A recent OIG study suggests that Medicare Advantage Organizations (MAOs) continue to routinely deny care to sustain their net revenue.
The OIG came to that conclusion based on their studies that show, upon appeal, MAOs overturn their own care denials a supermajority of the time.
The OIG is also concerned that a decreasing number of denials are being submitted each year, less than 1% in 2016.
So, insurance companies deny care to protect their margins, knowing that only a small number of patients will bother to appeal---no surprise.
But that doesn’t make it a wise policy in the long run.
Medicare Advantage continues to generate explosive growth and until that changes there is little incentive for MAOs to address this foolish behavior.
What can you do?
Play the “good guy.”
Don’t be afraid of appealing adverse coverage decisions. It’ll bond your patients to you for life.
Remember, it’s the relationship with your patient that generates the real value in Medicare Advantage.
Better yet, leverage your excellent financial performance under your Medicare Advantage contract to do away with certain prior authorizations completely. That’s what we did and it was amazingly successful at boosting our performance and our patient numbers.
Too many organizations approach their Medicare Advantage contract with a scarcity model. Relying on care denials to give them plausible deniability with their patients on one hand while cashing their checks with the other.
This is exactly wrong.
Take great care of your patients.
Fight the care denials.
The money you spend on their services will return to you a hundred fold.