5.6M+ Medicare claims denied over 6 years & other findings from study of Medicare coverage policies

Medicare and Medicare Advantage coverage policies resulted in more than 5.6 million claim denials between 2014 and 2019, according to a new study published in the January issue of Health Affairs.

For the study, researchers worked with Aetna and Medicare data to assess the number and cost of denied claims resulting from Medicare and Medicare Advantage coverage policies. Researchers used five years of claims data from Medicare and Aetna's Medicare Advantage plans. The study included both inpatient and outpatient claims, but didn't look at prior authorization denials.  

Six things to know:

1. The amount of denied spending resulting from coverage policies between 2014 to 2019 was $416 million, or about $60 in denied spending per beneficiary.

2. Nearly one-third of Medicare beneficiaries, 31.7 percent, received one or more denied service per year. 

3. Medicare coverage rules on average accounted for 85 percent of denied services and 64 percent of denied spending. Aetna's specific Medicare Advantage coverage rules accounted for the remainder of denied services and spending.

4. Most denied services under Medicare and Medicare Advantage coverage rules were laboratory procedures, followed by oncologic procedures. 

5. Researchers found that the denied spending was less than 1 percent of annual Medicare spending, but that this rate grew over time. In particular, researchers found denial rates rose 15 percent during the study period, and denied spending climbed 60 percent.

6. "Our findings provide initial evidence on the restrictiveness of government and private insurer medical necessity policies in Medicare, which led to payment denial for modest but nontrivial portions of medical services and spending," the study authors said. 

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