Medicare Advantage plans deny the most inpatient level-of-care claims: report

Initial clinical denial rates rose in 2022 with the highest denial rates coming from Medicare Advantage plans, according to a Feb. 15 report from Crowe Revenue Cycle Analytics.

Crowe's software monitors every patient financial transaction from more than 1,700 hospitals and 200,000 physicians, according to a Feb. 15 news release from the firm. 

Four things to know: 

1. Through November 2022, the dollar value of initial clinical denials by payers represented 3.2 percent of billed inpatient dollars. That is 18.5 percent higher than in 2021. 

2. Providers wrote off 3.6 percent of their inpatient revenue as uncollectible in 2021. That number increased to 5.9 percent in 2022, through November.  

3. The initial inpatient level-of-care claim denial rate for Medicare Advantage plans was 5.8 percent in 2022, through November. That is compared to 3.7 percent for all other payer categories. 

4. Clients in Crowe's benchmarking data wrote off $535.4 million on account of Medicare Advantage plan denials based on lack of medical necessity. 

"Given the immense popularity of these plans, healthcare providers will have to adjust their clinical operations and should ensure their revenue cycle and care management teams are in alignment on which denied claims should be prioritized when managing appeals," Colleen Hall, managing principal of the healthcare group at Crowe, said in the release.  

Read the full report here

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