Beneficiary Appeals in Medicare Advantage
An OIG report on Medicare Advantage Organization (MAO) beneficiary appeals found that MAOs make the vast majority of “organization determinations” (expedited reviews of benefit determinations) in favor of beneficiaries, with very few denials. Of the few denials that were appealed by beneficiaries, more than half were overturned by the MAO. At the second level of appeal, Independent Review Entities (IRE) overturned about one in five adverse MAO decisions. The OIG noted potential concerns regarding the low rate of beneficiary appeals, problems with timeliness in processing adverse expedited determinations, and the higher IRE overturn rate of expedited cases.
