2024 Coding Guide: Part 2 - Medicare Advantage

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Part 2: Medicare Advantage

5 strategies to address prior authorization challenges

Prior authorizations in Medicare Advantage plans are a growing problem. The news doesn’t necessarily paint a pretty picture. An investigation by the Office of Inspector General of the U.S. Department of Health and Human Services found that Medicare Advantage plans improperly applied Medicare coverage rules to deny 13% of prior authorization requests and 18% of payments. A Kaiser Family Foundation analysis found Medicare Advantage plans denied 2 million prior authorization requests in whole or in part, and although providers only appealed approximately 11%, the vast majority (82%) of those were fully or partially overturned.

Prior authorizations for Medicare Advantage are extremely challenging for medical practices especially as the number of patients enrolled in these Medicare replacement plans continues to increase, says Toni Elhoms, CCS, CPC, CPMA, CRC, CEO at Alpha Coding Experts in Orlando, Florida. “Medicare Advantage plans update their list of services requiring prior authorization frequently, and unless providers go to the payer portal to review the information, they might not even know,” she adds.

Here are five ways to reduce prior authorization-related denials with Medicare Advantage plans:

1. Designate someone in the practice to monitor Medicare Advantage payer portals. Charge this person with noting any changes in prior authorization requirements and building a cheat sheet that’s updated daily, if needed, Elhoms says.

2. Create Medicare Advantage prior authorization alerts in the billing system. The goal is to streamline efficiency by keeping all staff in the loop, says Richelle Marting, J.D., M.H.S.A., RHIA, CPC, an attorney at Marting Law in Olathe, Kansas. Note that many Medicare Advantage plans now require prior authorizations for in-office imaging, X-rays and other procedures, she adds.

The same is true for services such as principal care management and chronic care management, Elhoms says.

3. Strengthen Medicare Advantage contract language. “Small- and medium-sized practices can be at a disadvantage because they don’t necessarily have the bargaining power to change contract language,” Marting says. However, including language that requires the Medicare Advantage plan to follow all Medicare rules can be particularly helpful. “It doesn’t create a new obligation or requirement, but it very clearly gives that practice an enforcement mechanism,” she adds.

4. Form a collective strategy.
“I encourage physicians to talk to their professional associations, state medical societies or even the American Medical Association, especially when there are plans that deny claims improperly,” Marting says. “This feedback informs advocacy work to reform the system and promote corrective action.”

5. Involve patients. One strategy that could work, especially in primary care where patient-provider relationships are strong, is to ask patients to call their Medicare Advantage plan to obtain prior authorization, Marting says. “Doing this tends to have a better success rate in terms of avoiding denials,” she adds.

Practices can also work with patients to appeal denials. “Many providers are finding that when patients personally send an appeal letter, it’s more effective than if the provider were to do it,” Marting says.

Finally, providers can leverage patient frustration by directing them to the Medicare website where they can file grievances against a Medicare Advantage plan, Elhoms says. Visit here to learn more about the process.

Looking ahead

Ultimately, if a Medicare Advantage plan routinely denies and delays payments, physicians must ask themselves whether they want to contract with it. “If you have to jump through hoops to get paid, why are you doing it?” Elhoms asks.