Medicare Advantage Plans: Navigating Conditional Payment Appeals


by P. Czuprynski

Federal regulations require Medicare Advantage Plans (MAPs) establish an administrative appeal process that allows a Qualified Independent Contractor, an Administrative Law Judge, the Medicare Appeals Council, and the Federal Courts to determine if conditional payments require reimbursement.

MAPs hire companies to handle reimbursement requests for conditional payments, these companies are generally called “lien servicers.” IMPAXX has discovered lien servicers for Medicare Advantage Plans who fail to provide any administrative appeal process for their decision that conditional payments require reimbursement. Despite these denials, IMPAXX is appealing these decisions to the Social Security Administration.

If you do not agree with a MAP’s decision that conditional payments require reimbursement, the MAP should offer information regarding their administrative appeal process and details on how to appeal their decision. In these circumstances, you can also work with a specialist in conditional payments to assist in directing or appealing the reimbursement request.

While the non-group health plan industry has an interest in resolving claims quickly, Medicare Advantage Plans should not be able to benefit from these circumstances, without offering an administrative appeal process that follows federal regulations.

IMPAXX continues to push these issues before Medicare Advantage Plans and the Social Security Administration for our customers and Medicare stakeholders. We will provide additional information as we learn more.

If you have any questions on Conditional Payments and Medicare Advantage Plans and/or how we can advocate on your behalf, please contact us at [email protected].