Navigating Medicare Advantage Disputes — A CMS Escalation Guide 

Elizaveta Bannova, Billing Department, WCH 

Medicare Advantage (MA) disputes can significantly disrupt practice revenue and operations. For example, a claim for a patient’s colonoscopy may be downcoded despite complete supporting documentation. Initial appeals to the plan are denied, and subsequent escalations bring no resolution. After the plan’s internal process is exhausted, months have passed, and payment remains outstanding. 

This scenario is common. In 2023, Medicare Advantage insurers processed nearly 50 million prior-authorization requests, of which approximately 3.2 million (6.4%) were fully or partially denied. Separately, a large claims analysis found that 17% of initial MA claim submissions were denied, compared with roughly 8% in traditional Medicare—these metrics reflect distinct aspects of the denial landscape (definitions below). When internal options are depleted, providers have a direct escalation pathway to the Centers for Medicare & Medicaid Services (CMS).  

Read more: Navigating Medicare Advantage Disputes — A CMS Escalation Guide