| blueash |
10-31-2024 10:59 AM |
Quote:
Originally Posted by rsmurano
(Post 2382931)
Advantage plans are flawed, all of these issues have been known for many years (almost 70% denial rates when Medicare does not deny any procedure), and they keep getting worse
|
You wouldn't happen to have evidence for that 70% denial would you. Because if it were true nobody would be on a MA plan and everyone would be experiencing denials of over 1/2 their charges. It simply is not true.
Here's one reference I easily found
Quote:
Nearly 15% of all claims submitted to private payers initially are denied, including many that were preapproved during the prior authorization process. Overall, 15.7% of Medicare Advantage and 13.9% of commercial claims were initially denied.
More than half of denied claims (54.3%) by payers ultimately were overturned but typically only after providers went through multiple rounds of costly appeal
|
And another article looking at hospital system charges
where the Medicare Advantage initial claim denial was 15% and the TRADITIONAL MEDICARE denial rate was 8.4 %. So your claim that Medicare never denies is also wrong.
Now this is for payment, not authorization. So what is the rate of denial of prior authorization by Medicare Advantage?
Try this highly reliable source using 2022 data, KFF
Quote:
In 2022, insurers fully or partially denied 7.4% prior authorization requests
The vast majority of appeals (83.2%) resulted in overturning the initial prior authorization denial.
|
Well that means that for things requiring prior authorization, which most do not, the final rejection rate is 1.3 % not the ridiculous 70% you throw out to scare people. And I suspect 1.3% of people wanted things that were not medically needed... I want an MRI because I had two headaches last year kind of requests. |
