Testimonial
... CONTINUED FROM PAGE 2 “CMS oversees an entity’s continued compliance with the requirements for an MA organization. If an entity no longer meets those requirements, CMS terminates the contract in accordance with procedures described in Subpart K at 42 CFR Part 422.” None of us would write a blank check for someone. We want guarantees that our money is spent correctly. Medicare Advantage Organizations (MAO) also oversee that requests for reimbursement for treatments and procedures are within the standards of care that CMS authorizes. An issue has come up recently: Are MAOs too restrictive in their approvals of prior authorizations? After all, on the reverse side, the motivation for profits could motivate MAOs to restrict payments to keep revenue received from CMS for themselves. Unfortunately, CMS does not currently require the MAOs to keep data on some aspects of prior authorization rejections. The two most recent studies are inadequate for giving a real idea. Kaiser Foundation studied 35 million prior authorizations and found that less than 5% (or 2 million) were denied. It also noted that 82% of denials were overturned when appealed. The Health and Human Services Office of Inspector General did a tiny study of less than 250 denials during one week in 2019. Among those denials, the OIG determined that 18% (or 33 cases) should not have been denied. The reasons for denials were not completely clear, though human error and lack of supporting documentation were the dominant reasons.
“After I acknowledged that I was nearing Medicare age, I realized I knew nothing
about it so I reached out to two very informed friends. They both recommended Chris Grimmond. They praised his knowledge and helpfulness so I gave him a call. After meeting with Chris, I was 100% convinced that we would be working together. He answered all my questions and helped me understand the Medicare system. I feel confident I made the right decision to work with Chris and his team at Omaha Insurance Solutions.” –Cheryl A.
Inspired by FoodAndWine.com
Spring Herb Soup With Orzo and Pancetta
An objective and thorough study would be beneficial to dispel misunderstandings and false fears.
Ingredients • 3 tbsp extra-virgin olive oil • 4 oz pancetta, diced • 1 medium yellow onion, finely chopped • Salt and black pepper, to taste • 1/2 cup dry white wine • 1 cup uncooked orzo • 2 large garlic cloves, minced • 1 tsp fennel seeds • 1/2 tsp crushed red pepper
• 8 cups chicken broth • 1 15-oz can cannellini beans, drained • 1/2 cup chopped fresh chives • 1/4 cup chopped fresh tarragon • 1 1/2 cups chopped parsley • Pecorino Romano cheese, grated (for garnish) • Lemon wedges
In my experience, prior authorizations that are denied do not require a formal appeal. The denial is based on wrong codes, insufficient documentation, human error, and a lack of persistence. The real question is not why Medicare Advantage has prior authorization. Instead, it is why Original Medicare does not protect patients and taxpayers from fraud, waste, and abuse with its own prior authorization protocols.
Directions 1. Heat oil in Dutch oven over medium heat. Add pancetta and cook 4–6 minutes. Add onion, salt, and pepper; cook until softened, 8–12 minutes. 2. Add wine and cook 4–5 minutes. Add orzo, garlic, fennel seeds, and red pepper; cook, stirring constantly, 2–4 minutes. 3. Add broth; bring to a boil. Reduce heat and cook until orzo is al dente, 8–10 minutes. 4. Reduce heat to low. Stir in cannellini beans; cook about 2 minutes. Remove from heat. Stir in chives, tarragon, and parsley. Season with salt and pepper. Top with cheese and lemon.
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