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Denials and Appeals in Medicare Part C

CMS uses a capitated payment model to pay private insurers that provide health care services under Medicare Part C. Capitated payment models are on a payment-per-person rather than a payment-per-service basis, and they can create an incentive to deny access to services or payment in order to increase an insurer's profits. We will examine national trends and CMS's oversight of denied care and payment in Part C during 2014-2016. Beneficiaries and providers can appeal denied services and payments to multiple levels of review within the administrative appeals process. We will determine the extent to which denials that have been appealed to each level of review were overturned. We will examine variations in appeals and overturned denials across Part C contracts. We will also evaluate CMS's efforts to monitor and address inappropriate denials in Part C.

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

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