Medicare Advantage plans are not required to identify when payments claims were denied, hindering fraud, waste and abuse investigations, according to a new report from HHS' Office of Inspector General.
Unlike fee-for-service Medicare and Medicaid, Medicare Advantage plans do not have to indicate which claims are denied in encounter records. According to an OIG report published March 2, MA plans submit adjustment codes when they do not pay the full amount billed for a claim. These codes do not always indicate if a claim was denied, according to the OIG.
The watchdog organization recommended that CMS require organizations to definitively indicate when claims have been denied. The agency did not concur or nonconcur with OIG's recommendation.
Of all payer types, Medicare Advantage plans have the highest rates of claim denials for inpatient services, according to a report from Crowe Revenue Cycle Analytics.