Some Medicare Plans Deny Valid Requests

When it comes to Medicare, what option is best for you—Original Medicare or Medicare Advantage (MA)? Many people are drawn to Medicare Advantage plans, sometimes knowns as all-in-one plans, because they often combine healthcare with vision, dental, hearing, and drug coverage, something Original Medicare doesn’t do.

But the Office of the Inspector General (IG) at the U.S. Department of Health and Human Services is warning that some MA plans have denied valid requests for treatment pre-approval and payment for services for medically necessary treatments.

The Inspector General’s Office reviewed 500 denials for prior authorizations and payments from 2019 by 15 of the largest Medicare Advantage providers. It turned out that 13% of prior authorization requests that had been denied and 18% of the denied payment requests did, in fact, meet Medicare’s coverage rules. The IG concluded that those denied requests would most likely have been approved if they had been submitted to Original Medicare.

According to the IG, unnecessarily denying prior authorization or payment can:

  • Delay or prevent patients from getting needed health care
  • Cause patients to pay for treatment out of pocket
  • Create an administrative nightmare for both patients and healthcare providers


The investigation found that 3% of the denials for prior authorization and 6% of denied payments had been reversed by the insurance companies when patients appealed the decisions. But even when a denial is reversed, there can be significant delays in a patient getting necessary healthcare.



With the investigation complete, the Inspector General has made recommendations to rectify the problems that were uncovered.

  • The Centers for Medicare and Medicaid Services will issue new guidance and audit protocols to eliminate the denial of valid prior authorization and payment requests.
  • Medicare Advantage plan providers will be directed to review their systems and correct “vulnerabilities” that allow denial of valid requests.


So, what can you do if you have a Medicare Advantage plan and you’re concerned? First, talk to your current provider and see if they’re correcting any problems that have led to denial of valid requests. Second, you can switch Medicare Advantage plans or change to Original Medicare during the annual Open Enrollment Period, October 15-December 7, or during the annual Medicare Advantage Open Enrollment Period, January 1-March 31.

If you decide to switch to Original Medicare, be aware that it only pays 80% of Medicare approved expenses. The remaining 20% comes out of your pocket, unless you purchase a separate Medicare Supplement plan, which is sold by private insurance companies. Unlike Medicare Advantage plans, Original Medicare does not provide for vision, dental, hearing, and prescription drugs. To get those coverages, you will have to buy them as separate policies.

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