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Inappropriate Denial of Services and Payment in Medicare Advantage

Capitated payment models are based on payment per person rather than payment per service provided. A central concern about the capitated payment model used in Medicare Advantage is the incentive to inappropriately deny access to, or reimbursement for, health care services in an attempt to increase profits for managed care plans. We will conduct medical record reviews to determine the extent to which beneficiaries and providers were denied preauthorization or payment for medically necessary services covered by Medicare. To the extent possible, we will determine the reasons for any inappropriate denials and the types of services involved.

Announced or Revised Agency Title Component Report Number(s) Expected Issue Date (FY)
June 2018 Centers for Medicare & Medicaid Services Inappropriate Denial of Services and Payment in Medicare Advantage Office of Evaluation and Inspections OEI-09-18-00260 2020

Office of Inspector General, U.S. Department of Health and Human Services | 330 Independence Avenue, SW, Washington, DC 20201