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Denials and Appeals in Medicare Part C and Part D

Capitated payment models are based on a payment per person rather than a payment per service provided. A central concern about the capitated payment models used in Medicare Part C and Part D is the incentive to inappropriately deny access to services or prescription drugs in an attempt to keep health care costs low. We will examine national trends and oversight by the Centers for Medicare & Medicaid Services (CMS) of denied care within Part C and Part D. We will determine the extent to which services and prescription drugs were denied, and the extent to which the denials were appealed and overturned in Part C and Part D from 2014 to 2016. We will also compare rates of denials, appeals, and overturns across Part C and Part D contracts, and evaluate CMS's efforts to monitor and address inappropriate denial of care. Future work in this area may include medical record reviews to examine whether denials are appropriate.

Announced or Revised Agency Title Component Report Number(s) Expected Issue Date (FY)
Nov-16 Centers for Medicare & Medicaid Services Denials and Appeals in Medicare Part C and Part D Office of Evaluation and Inspections OEI-09-16-00410 2018

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