Playing Smart Defense Against Medicare Denials

Whether your team won or lost the Super Bowl, we can all appreciate a good sports metaphor. Hospitals and healthcare systems face daily challenges with inpatient payment denials from Medicare Advantage companies. While an offensive strategy would be ideal, playing smart defense might be the best way to reduce these denials for now. Medicare Advantage companies have a strong and smart offense, insuring 54% of Medicare beneficiaries, with expert clinical review teams and Ai to increase denial rates.

 

Know the Medicare Advantage Offensive Targets

Think of Medicare Advantage companies as having a strong offense with key players:

• MS DRGS 871-872 (Fullback and Halfback): These DRGs get the most touches.
• MS DRGS 291-293 (Tight Ends): Used in the quarterback run-pass option.
• MS DRGS 177-179 (Wide Receivers): Easy targets when your defensive backs aren’t alert.

Defending Against a Strong and Smart Offense

It all starts with clinical documentation. Use all players on your defensive squad, including Clinical Documentation Specialists and HIM professionals. These players must keep doctors informed about the weak spots in your documentation (defense).

• MS DRG 871-872 (Sepsis): Medicare Advantage uses their interpretation of Sepsis-3. Ensure organ failure/dysfunction due to sepsis is clearly linked. Watch your length of stay; a stay of less than 4 days may generate an automatic denial.
• MS DRG 291-293 (Heart Failure): Medicare Advantage looks for the presence of the Framingham criteria, a description of a sick patient, and treatment consistent with acute or decompensated heart failure.
• MS DRG 177-179 (Complex Pneumonia): Link positive cultures and lab tests to the pneumonia. Match the duration of treatment and antibiotics to a complex pneumonia. Document in the discharge summary that a probable or proven complex pneumonia is present and treated.

Teamwork and Communication

1. They flood the field with denials.
2. They anticipate that only 11% of denials will be appealed.
3. They target MS-DRGs responsible for most inpatient medical admissions.
4. You can win on appeal: Up to 80% of appeals may be partially or completely overturned.

Denial rates are rising, and it looks like they may cross 20% of claims submitted for in-network claims in 2025. Medicare Advantage companies move the goalposts, so stay alert. Know the MS-DRGs being denied and when the denial is for clinical validity. Appeal when you can and learn from the appeals you cannot defend. Keep your team informed.

 

While it’s great to be on the offense, in 2025, playing strong defense may be your best strategy. Prevention is less expensive and disruptive than appealing a denial.