Watchdog to CMS: Track Medicare Advantage Claim Denials

Christi Grimm has an idea for improving Medicare Advantage plan regulation: Put information about denials in patient records.

If a Medicare Advantage plan added a code to an enrollee's encounter record when it denied a claim, investigators would have an easier time using the records to identify provider fraud, Grimm says.

Investigators would also have an easier time seeing if plans deny claims in an improper way, she adds.

Grimm, the inspector general for the U.S. Department of Health and Human Services, and other officials in her office discuss the lack of a Medicare Advantage claim denial code in a new HHS Office of the Inspector General report to Congress.

What It Means

Regulators have no simple way to determine if Medicare Advantage plans are denying too many of your clients' claims.

The Missing Code

In the new report, HHS OIG officials highlight a Medicare Advantage claim denial review the agency released in February.

"We found that there is no definitive method to identify denied claims in the Medicare Advantage encounter data and that the lack of a denied-claim indicator in these data hinders program integrity oversight," officials said.

The Centers for Medicare and Medicaid Services, the arm of HHS that runs Medicare, does require Medicare Advantage plans to add explanatory codes when they pay health care providers less than the billed amount.

CMS uses those codes when determining how much it should pay plans.

Because CMS does not need information about claim denials to calculate the plan payments, it has not asked for denial codes.

CMS should start asking for denial codes to help HHS OIG and other entities do a better job of analyzing its paid claims and denied claims, HHS OIG officials suggested.

Pictured: HHS Inspector General Christi Grimm. (Photo: HHS OIG)

Watchdog to CMS: Track Medicare Advantage Claim Denials

What It Means

The Missing Code

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Watchdog to CMS: Track Medicare Advantage Claim Denials

What It Means

The Missing Code

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