An all-too-common complaint about Medicare Advantage (MA) plans is that they either deny claims that traditional Medicare fee-for-service would have approved, or that they require equipment providers, clinicians and patients to take extra steps to qualify for equipment — additional hoops to jump through that traditional Medicare would not have required.
Those additional MA steps often require the patient to be trialed on lesser equipment, even when the prescribing physician previously determined such equipment would not meet the patient’s needs and would not achieve the outcomes the physician wants.
Here — in the words of Noel Neil, JM, CDME, VP of Auditing and Corporate Compliance for
ACU-Serve Corp. — is a case example of a ventilator that was initially denied by the patient’s MA plan, but was appealed all the way up to the departmental appeals board (DAB).
Mobility Management: Without sharing confidential information, what’s the background on this patient?
Noel Neil: We have a client in Alabama who has COPD [chronic obstructive pulmonary disease] and severe respiratory illness. And his doctor, who has been treating him forever, says, “We cannot give this patient a BiPAP because of the patient’s CO2 retention.” So there’s well-documented evidence as to why a ventilator is the only appropriate choice for that patient.
The [MA plan] denied it, and the doctor and the supplier, working together, challenged the denial all the way up to the ALJ [administrative law judge] level. The judge agreed with the doctor and the supplier.
[The MA plan] did nothing, but challenged that decision to the level above, which is the DAB and takes a lot longer than the ALJ. So the DAB finally came back and issued a favorable decision that they agreed with the judge, the doctor and the supplier — that a vent should be reasonable and necessary.
The DAB decision took exactly one year. So we’re not talking about a process that takes a couple of weeks or a couple of months. Think about it: If a patient truly needed a vent, could they sit around a year waiting on an administrative process to go through? It’s impractical.
MM: Meanwhile, during that year of waiting, what has happening with the patient?
Noel Neil: So thankfully, this [provider] is a family-oriented company; they’re rural. They truly believe in helping the patient. They gave the patient a vent and just weren’t charging the patient. So the patient had the vent for a year during that process.
At the end of the decision, [the MA plan] could have challenged and taken this to the district court, if they disagreed. But they basically reached out and asked us if the [patient had the] vent. And we said, “Well, yes, we had to give it to them, even though we knew there was no guarantee of payment.”
MM: So if the patient had lived for that year without a ventilator, the MA plan would likely have contended that the patient didn’t need the vent? But they changed their mind upon learning that the supplier had provided the vent free of charge during that time?
Noel Neil: The MA decided not to challenge it anymore. And internally, they gave their team the instructions that they should pay the claim.
MM: So thanks to great perseverance, the provider and patient won.
Noel Neil: But not every supplier is going to dispense vents and wait a whole year to get paid. It’s not practical. And not everybody’s willing to fight to the levels that we did with this patient.
This is just one example that I was committed to it seeing through. But this is the reality of many patients all across the country. And most times, providers just don’t have the resources to fight and challenge the appeal. So those determinations stand.
Editor’s note: This is a companion story to “CRT’s Problem with Medicare Advantage,” published in the August 2024 Mobility Management ebook. Read more about Medicare Advantage starting on page 8 in the August 2024 Mobility Management ebook.