Revenue Cycle

Insurers must correct Medicare practices

Patient Financial Services Weekly Advisor, October 12, 2007

The nation's largest insurers in the Medicare market use illegal marketing strategies and falsely deny claims of Medicare recipients, according to a report in the New York Times.

Federal officials this week released 91 audit reports that say some insurers who run Medicare's new drug benefit program are:

  • too far behind in their claims and complaints
  • not answering phone calls in a proper timeframe
  • improperly terminating claims from beneficiaries.

    The findings target three major insurers and list specific problems with each:

  • UnitedHealth, which serves more than six million Medicare recipients, did not effectively supervise its marketing agents and denied claims without an explanation
  • Wellpoint, one of the nation's largest insurers, had 354,000 claims backed up, the Times reports
  • Humana, which covers 4.5 million people on Medicare, could not keep up with all its complaints

    Since March, when Medicare told insurance companies to patch their holes with "corrective action plans," fines for 11 insurers have totaled $770,000, the Times reports.

    The Department of Health and Human Services conducted the audits. Medicare officials said the most apparent problems were how insurers marketed and processed appeals and grievances.

    John H. Wells, compliance officer at Bravo Health, which was audited by federal officials, said the government needs to be more transparent about its regulations. "The appeals and grievances process is very complex," he tells the Times. "It is very difficult for any plan to be fully compliant. In many cases, the government's guidance is unclear, so it's impossible for a business to know what to do."

    To read the full story in the New York Times, click here.

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