The expedited appeals process in Medicare Advantage (MA) is a secret weapon for overturning pre-service benefit denials, but it’s underused by hospitals, a physician advisor says. CMS allows physicians and other hospital clinicians to fast-track certain MA appeals on behalf of patients, while shifting the burden to MA plans to justify denials. But patients and physicians may not know about this pathway partly because it’s hard to locate on denial notices.

“This has been game-changing,” says Brian Moore, M.D., medical director of utilization management and physician advisor services at Atrium Health in North and South Carolina. He has won all 25 of the preauthorization challenges mounted with expedited appeals, and also files grievances when MA plans don’t comply with CMS regulations on expedited appeals. Yet the one-two punch of expedited appeals and the grievance process is “vastly underutilized,” Moore says. Although it takes time and a high tolerance for frustration, Moore recommends the strategy, especially as MA enrollment numbers climb. “Expedited reconsiderations are getting denials overturned,” says Moore, chairman of the American College of Physician Advisors’ government affairs committee. They are intended for benefit denials, not payment denials.

According to CMS regulations, enrollees or physicians may request expedited determinations from MA plans before the claims are paid. That’s why Moore says it’s particularly useful for pending admissions to post-acute care—skilled nursing facilities, inpatient rehabilitation facilities, and long-term care hospital admissions—from acute-care hospitals. Enrollees and physicians may file expedited appeals directly, and other hospital clinicians, such as case managers (who are usually nurses), also may file expedited appeals on their behalf when enrollees sign “appointment of representative” (AOR) forms. “If someone who is not a physician is initiating this, a supporting statement from a physician is needed,” Moore says.