Medicare Advantage plans offer an interesting (disturbing?) insight into how often these privatized plans inappropriately deny radiotherapy services.
The Study:That’s because “inappropriate” can be pretty objectively determined here by a true third party (i.e. not paid per denial) Independent Review Committee that reviews appeals based on true Medicare coverage guidelines. Remember, these private plans explicitly state they cover all the same services as Medicare, albeit at fewer sites of service. A detailed analysis of now publicly available data spanning 2022-2024 reveals the rate of inappropriate Medicare Advantage denials across all health services was 4.7%. Compare that to 17.4% for radiotherapy services. The rate of inappropriate denials was more than 3-fold higher for radiotherapy than other services for each calendar year. Denials for SBRT, specifically, were inappropriate 26% of the time and for IMRT 41%. A standout was breast IMRT denials clocking in as inappropriate in a whopping 81% of cases. Action items? From a systems perspective, it is already the case that surpassing a certain threshold for inappropriate denials can decrease Medicare payments to these privately owned Medicare Advantage plans—thus the independent third party review. The problem is they can skirt under the threshold set for all services while still denying an objectively unacceptably high rate of radiotherapy services. The authors suggest services with the highest rates of inappropriate denials should be weighted the highest the following calendar year and adjusted annually in order to truly create a financial incentive for better behavior across health services. What can Joe the Rad Onc do? The authors highlight that only roughly 1 in 10 initial denials are appealed in the first place by evermore demoralized physicians. This data suggests rad oncs have a 15% chance of winning on appeal and much more for certain procedures such as breast IMRT.
TBL: Take the time to appeal your denials, particularly for services with high chances of succeeding on the third party appeal mechanism for Medicare Advantage plans. | Pasetsky, Int J Radiat Oncol Biol Phys 2024
The Study:That’s because “inappropriate” can be pretty objectively determined here by a true third party (i.e. not paid per denial) Independent Review Committee that reviews appeals based on true Medicare coverage guidelines. Remember, these private plans explicitly state they cover all the same services as Medicare, albeit at fewer sites of service. A detailed analysis of now publicly available data spanning 2022-2024 reveals the rate of inappropriate Medicare Advantage denials across all health services was 4.7%. Compare that to 17.4% for radiotherapy services. The rate of inappropriate denials was more than 3-fold higher for radiotherapy than other services for each calendar year. Denials for SBRT, specifically, were inappropriate 26% of the time and for IMRT 41%. A standout was breast IMRT denials clocking in as inappropriate in a whopping 81% of cases. Action items? From a systems perspective, it is already the case that surpassing a certain threshold for inappropriate denials can decrease Medicare payments to these privately owned Medicare Advantage plans—thus the independent third party review. The problem is they can skirt under the threshold set for all services while still denying an objectively unacceptably high rate of radiotherapy services. The authors suggest services with the highest rates of inappropriate denials should be weighted the highest the following calendar year and adjusted annually in order to truly create a financial incentive for better behavior across health services. What can Joe the Rad Onc do? The authors highlight that only roughly 1 in 10 initial denials are appealed in the first place by evermore demoralized physicians. This data suggests rad oncs have a 15% chance of winning on appeal and much more for certain procedures such as breast IMRT.
TBL: Take the time to appeal your denials, particularly for services with high chances of succeeding on the third party appeal mechanism for Medicare Advantage plans. | Pasetsky, Int J Radiat Oncol Biol Phys 2024