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New Paper Suggests Needed Changes to Medicare Appeals Processes

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The American Cancer Society Cancer Action Network released a paper this week that outlines problems and potential solutions for various issues within Medicare appeals processes. The hurdles in various appeals processes can pose insurmountable burdens for people with Medicare who need access to care, services, medication, and items.

Two key findings from the paper are that the processes are overly complex and can take too long. At Medicare Rights, our national helpline experience contributed to the paper and aligns with its conclusions. We agree that appeals processes should be streamlined and the burdens on beneficiaries must be reduced to ensure more people have access to the benefits they need.

In addition, the paper flags that some Medicare plans may be inappropriately denying care. This warning is consistent with findings from the Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services—a watchdog agency that oversees the Medicare and Medicaid programs. The OIG found that Medicare Advantage organizations appeared to regularly and inappropriately deny coverage and would only reverse course when the decisions were appealed. This is very concerning, as we know that many people do not appeal denials—either paying out of pocket or going without care entirely because they do not know about their appeal right or because the process is daunting and confusing.

Because many of the data on Medicare plan denials are not publicly available, it is difficult to know precisely how widespread problems may be. But we regularly hear from callers on our national helpline who are struggling with denials, frustrated with appeals, and unable to afford health care costs out of pocket.

More must be done to streamline, simplify, and improve appeals in all aspects of the Medicare program. In our most recent helpline trends report, we highlighted issues our callers face as they try to appeal Medicare Advantage decisions. We urge the Medicare program to increase its oversight of and penalties for Medicare Advantage Plans that inappropriately deny care.

We also support improvements to the Medicare Part D appeals process, such as more information being provided at the pharmacy counter. Bipartisan legislation such as the Streamlining Part D Appeals Process Act (116th Congress, S 1861, HR 3924) would allow a refusal at the pharmacy counter to serve as the plan’s initial coverage determination. This would give people with Medicare more timely information and eliminate unnecessary steps within the appeals process.

Read the paper.

Read more about inappropriate denials by Medicare Advantage.

Read more about improving Medicare Advantage appeals.

Read more about the Streamlining Part D Appeals Process Act and sign the petition.

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