OIG: CMS should require MA plans to identify denied claims

The Centers for Medicare & Medicaid Services should require Medicare Advantage organizations to definitively indicate when they deny payment of a claim for service, the Department of Health and Human Services’ Office of Inspector General recommended Friday. 

“We found that adjustment codes are not a definitive method for identifying denied claims in the MA encounter data,” OIG said. “The descriptions for some adjustment codes are too vague to clearly identify whether the MAO denied payment for a service. … We also found that most 2019 MA encounter records contained at least 1 adjustment code and 55 million of these records contained codes that may indicate the denial of payments by MAOs. However, without a definitive method for identifying denied claims in the MA encounter data, the full scope of payment denials in the data is unclear.”

In a separate report last year, OIG said CMS also should take steps to prevent MAOs from denying coverage and payment for medically necessary care. 

AHA has urged CMS and the Department of Justice to hold MAOs and other commercial health insurers accountable for inappropriately and illegally restricting beneficiary access to medically necessary care, and CMS to strengthen data collection and reporting of plan performance metrics meaningful to beneficiary access, including denials, appeals and grievances.