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DecisionHealth, DecisionHealth - 2011 Issue 2 (February)

Benchmark of the Week: Success of Medicare Advantage appeals, 2009

These charts offer a rare look at the success of appeals within Medicare Advantage (MA) plans, which do not often share their claims or appeals data with the public, unlike CMS. The first graph shows the percent of reconsiderations (second-level appeals) in which the MA plan’s decision was overturned (either partially or completely) or upheld (this also includes appeals that were dismissed). NOTE: All data comes from Maximus Federal Services Inc., a private contractor selected by CMS to act as the national independent review entity with oversight on MA denials. NOTE: Maximus only processes second-level appeals and does not have code-level data, a company official tells Part B News. The second graph shows the dollar amounts involved; all the data is from 2009.
 

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