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Medicare claim processing: an analysis of perceptions of lived experiences by health care executives and leaders regarding Medicare claim denials

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Medicare claim processing: an analysis of perceptions of lived experiences by health care executives and leaders regarding Medicare claim denials

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Content Medicare Claim Processing: An Analysis of Perceptions of Lived Experiences by Health
Care Executives and Leaders Regarding Medicare Claim Denials
Michael Scott Koslow
Rossier School of Education
University of Southern California
A dissertation submitted to the faculty
in partial fulfillment of the requirements for the degree of
Doctor of Education
August 2024

© Copyright by Michael Scott Koslow 2024
All Rights Reserved

The Committee for Michael Scott Koslow certifies the approval of this Dissertation
Ekaterina Moore
David Lenihan
Brian A. Rohrer
Douglas E. Lynch, Committee Chair
Rossier School of Education
University of Southern California
2024

iv
Abstract
This dissertation examined the perceived beliefs and impact of medical-provider-denied
Medicare claims and the associated Medicare claims appellate process. Recognizing the high
number of Medicare claims being denied, the relatively small number of those denied claims
processed for appeal, the considerable backlog of administrative law judge (ALJ) appellate
reviews, and the high number of appellate claim overturn rates, Medicare beneficiaries and
medical providers are severely disadvantaged when seeking reimbursement for medically
necessary treatments. The purpose of the study was to obtain and evaluate the collective
anecdotal inputs relating to issues associated with Medicare claims processing from the lived
experiences of health care executives. Administrative and clinical leaders within the medical
community possessing executive health care industry experience addressed the factors that may
contribute to the high number of Medicare claim denials with a commensurate Medicare
appellate denial overturn rate by the ALJs. Using qualitative research methods, industryrecognized health care executive medical practitioners, administrators, and academic leaders
were interviewed. These professionals did not have an overall high confidence in Medicare claim
denial justifications. In addition, the professionals stated that Medicare claim denials may
contribute to a reduced ability to deliver satisfactory and necessary medical care to Medicare
beneficiaries. This dissertation contributes to the available research indicating that beneficiaries
do have a proclivity to gravitate to medical practitioners within their own race or ethnicity and
that incorrectly denied Medicare claims may adversely impact the Medicare-eligible elderly
population.
Keywords: Medicare, Medicare administrative contractors, gap performance research
analysis, Office of Medicare Hearings and Appeals, claim denials

v
Dedication
To our vast aging population seeking satisfactory health care treatments and services when
receiving a diminished level of timely and medically supported medical care due to incorrectly
denied Medicare medical claims. This dissertation was motivated by the apparent adverse impact
on the millions of Medicare-eligible individuals who have their Medicare-submitted claims
denied and are unable to effectively appeal those decisions in order to receive justifiable
medically necessary treatments.
To those who supported and motivated me to be a task-driven and compassionate human being,
including my mother (deceased), father (deceased), stepfather Kenneth, and stepmother Patricia.
To my ardent fiancée, Dorothy, who has been the pinnacle of consistent support and patience and
a continual motivational beacon in ensuring I put forward the greatest effort and commitment in
successfully completing this long and arduous journey.

vi
Acknowledgments
I wish to extend my personal gratitude to my family, friends, cohort colleagues, and to all
who travelled this gratifying academic journey with me in the research and formulation of this
dissertation, Medicare Claim Processing: An Analysis of Perceptions of Lived Experiences by
Health Care Executives and Leaders Regarding Medicare Claim Denials.
Most notably, I want to recognize the extraordinary support I have received from my
good friends and classmates Dana Chisholm, Cheryl Moore, Yeong Tae Pak, and Philip
Consuega. Their collective support provided me with the incentive, motivation, and clarity of
purpose throughout the demanding 3-year process.
I am very appreciative of the members of my dissertation committee: Dr. Douglas E.
Lynch, Dr. Ekaterina Moore, Dr. David Lennihan, and Brian A. Rohrer, Esquire, for their
personal commitment and professional insights as I transitioned through each stage of this
research and evaluation process.
I also would like to thank Dr. Ted Y. Fisher, vascular surgeon, for providing me with the
vision and motivation to research this particular area of professional concern within the medical
billing environment. His personal resilience and commitment demonstrate a clear disparity
between providing valued medical care to Medicare-eligible beneficiaries and fulfilling an
administrative function.

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Table of Contents
Abstract.......................................................................................................................................... iv
Dedication....................................................................................................................................... v
Acknowledgments.......................................................................................................................... vi
List of Tables.................................................................................................................................. x
List of Figures................................................................................................................................ xi
List of Abbreviations.................................................................................................................... xii
Chapter One: Overview of the Study.............................................................................................. 1
Context and Background of the Problem............................................................................ 2
Purpose of the Project and Research Questions.................................................................. 4
Importance of the Study...................................................................................................... 5
Overview of the Theoretical Framework and Methodology............................................... 6
Organization of the Study ................................................................................................... 6
Chapter Two: Review of the Literature .......................................................................................... 7
The Role of Medicare in U.S. Culture ................................................................................ 8
MACs…………………………………………………………………………………….10
Impact on the Elderly—What Health Concerns Are Addressed and Covered ................. 11
Effects of Race and Cultural Competence........................................................................ 14
The Medicare Program and Claim Submission Process................................................... 20
Problem of Practice........................................................................................................... 22
Theoretical Framework..................................................................................................... 26
Chapter Three: Methodology........................................................................................................ 33
Research Questions........................................................................................................... 34

viii
Overview of Design .......................................................................................................... 35
Research Design................................................................................................................ 36
The Researcher.................................................................................................................. 40
Data Sources..................................................................................................................... 40
Sample and Population ..................................................................................................... 43
Instrumentation ................................................................................................................. 44
Data Collection ................................................................................................................. 44
Validity and Reliability..................................................................................................... 46
Ethical Standard................................................................................................................ 47
Limitations and Delimitations........................................................................................... 47
Chapter Four: Findings................................................................................................................. 48
The Participants ................................................................................................................ 50
The Qualitative Analysis................................................................................................... 52
Results for Research Question 1....................................................................................... 54
Results for Research Question 2....................................................................................... 55
Results for Research Question 3....................................................................................... 56
Summary of Findings........................................................................................................ 57
Chapter Five: Discussion .............................................................................................................. 59
Recommendations............................................................................................................. 59
The Significance of Economic Evaluations...................................................................... 64
The Concept of a Benefit-Cost Analysis .......................................................................... 69
Recommendations for Future Research............................................................................ 73
Conclusion ........................................................................................................................ 75

ix
References..................................................................................................................................... 77
Appendix: Interview Protocol....................................................................................................... 91
Introduction to the Interview ............................................................................................ 91
Research Question 1 Interview Questions and Potential Probes...................................... 92
Research Question 2 Interview Questions and Potential Probes...................................... 93
Research Question 3 Interview Questions and Potential Probes...................................... 93
Conclusion to the Interview.............................................................................................. 94

x
List of Tables
Table 1: Medicare Coverage 9
Table 2: Interview Questions for Research Question 1 37
Table 3: Interview Questions for Research Question 2 38
Table 4: Interview Questions for Research Question 3 39
Table 5: Study Participant Demographic Information 44
Table 6: Filtered Code Analysis in Order of Most Occurrences 53

xi
List of Figures
Figure 1: Gap Analysis of Health Care Executive Perceptions of Medicare Claim Processing 27
Figure 2: Health Status Among All Medicare Beneficiaries, 2021 42

xii
List of Abbreviations
ALJ Administrative law judge
CMS Centers for Medicare and Medicaid Services
DME Durable medical equipment
HHS U.S. Department of Health and Human Services
KFF Kaiser Family Foundation
MAC Medicare administrative contractor
MCBS Medicare Current Beneficiary Survey
OIG Office of Inspector General
OMHA Medicare Office of Medicare Hearings and Appeals

1
Chapter One: Overview of the Study
Since 2014, there has been repetitive controversy and discussion by the government and
the health care industry involving the adverse impact of Medicare denial of provider-submitted
claims and the subsequent significant number of those denied claims that are overturned on
appeal by the U.S. Department of Health and Human Services (HHS) Centers for Medicare and
Medicaid Services (CMS) Office of Medicare Hearings and Appeals (OMHA; Lerman, 2014;
Wachler & Associates, 2018; Wanerman et al., 2014). The Medicare program processes over 1
billion claims for over 60 million authorized beneficiaries annually (CMS, 2019). Wanerman et
al. (2014) posited that medical providers are being adversely impacted financially by being
forced to wait for up to 3 years to have their denied claims heard by a Medicare appellate
administrative law judge (ALJ). The protracted delays are compelling many providers to dissolve
their clinics and businesses due to a lack of adequate Medicare payment streams.
Only 1% of denied provider-submitted Medicare claims are appealed by the providers
(Office of Inspector General [OIG], 2018, 2019). Of that 1%, over 70% are subsequently
overturned by a Medicare ALJ at the third appellate level (there are five levels of appeal) within
the denied-claim appeals process by Medicare claim reviewers (OIG, 2018, 2019). Medicare
Administrative Contractors (MACs) are typically the first line of the medical provider-submitted
Medicare claim review process for payment approval (CMS, 2020). Effectively since 1966,
MACs under contract to the CMS have reviewed millions of claims and have a denial rate that
far exceeds 50% for certain types of categorical claims (e.g., peripheral vascular deficiency). The
denied claims adversely affect the payment of claims for necessary medical treatment of millions
of elderly beneficiaries.

2
In this research, I reviewed the role of the MAC claims reviewers in denying submitted
Medicare claims. I also studied the impact of a 25% or more claim reviewer denial rate. As
stated earlier, only 1% are challenged (appealed) and, of those 1% challenged, 70% are
overturned by a Medicare third-level appellate ALJ (OIG, 2018, 2019). The framework used was
the Clark and Estes (2008) performance gap analysis to explore the knowledge, motivational,
and organizational gaps of claims denied at the first Medicare appellate level by MAC claims
reviewers.
Context and Background of the Problem
According to Wanerman et al. (2014), the U.S. Medicare Advantage Program deniedclaims appellate submission processes adversely affect underserved populations by limiting
beneficiary payments to servicing medical providers. The OIG (2018) noted their Medicare
Advantage Organization contractors, or MACs (e.g., Noridian Healthcare Solutions), had 75% of
their own provider-submitted claims denials overturned between 2014 and 2016. The number of
Medicare Advantage Program beneficiaries has significantly increased in enrollment from 8
million in 2007 to over 21 million beneficiaries in 2018 (OIG, 2019). In addition, as of 2019,
Black, Hispanic, and other non-White beneficiaries over the age of 65 accounted for
approximately 32% of the total number of Medicare Advantage Program beneficiaries (CMS,
2019).
The CMS arguably recognizes the significant adverse impact it is having on its
beneficiary populations when its MACs deny such a significant percentage of claims following
inputs the CMS receives from the medical provider industry (Lerman, 2014). According to Alsan
et al. (2019), CMS instituted an inequitable system that adversely impacts medical provider
revenue streams, precluding them from operating their practices within underserved populations.

3
This inequitable environment limits lifesaving, medically necessary care and treatment for
underserved populations when they do not have an available medical practitioner who shares a
common demographic.
The purpose of CMS is to improve the lives of those they serve, including, or especially,
underserved populations such as ethnic minority and elderly groups. The CMS (n.d.) mission
statement is to serve Medicare and Medicaid beneficiaries. In addition to the other purposes
noted, the study focuses on the benefit cost to the organization from a high denial rate in the
preliminary stages of the appellate process. The study includes the perceptions of health care
executives and leaders, particularly their confidence and ability to prepare and submit clean
claims for Medicare claim reimbursements. I also examined the role of the MAC Medicare
organizational claims reviewers who are denying submitted provider Medicare claims at an 18%
or greater denial rate. A preliminary review and evaluation of general medical data contained
within Medicare’s publicly available database systems allowed a comprehensive evaluation of
the data covering multiple years. The evaluation provides a trend analysis of ailments,
geographic data, gender, age, and race from general medical data reported via Medicare survey
results associated with interviewed Medicare beneficiaries.
A benefit-cost analysis includes Medicare general medical survey results and OIGreported data reporting the number of annual submitted claims to Medicare as a percentage of the
total number of denied claims for that same universe of submitted claims, the number and
associated denial reasons (administrative vs. medical necessity), the number and type of claims
overturned by OMHA ALJs, and the delta between the number of denied Medicare claims
(categorized by medical condition) and the number of ALJ-overturned claims for the universe of

4
denied Medicare claims. The resultant data analysis provides insights into the possible benefit
cost to the Medicare organization of permitting the high claim denial rate.
The literature review focused on the structure and history of the Medicare program; the
component of the U.S. population eligible to receive Medicare benefits; and the Medicare claim
submission approval, denial, and denied claims appeal process. Medicare claims may be denied
for a number of reasons, but the majority of claims are incorrectly denied for administrative or
technical irregularities identified within the submitted claims. The literature has reflected that
Medicare appellate reviews can be delayed for as long as 3 years (Wanerman et al., 2014). The
literature further reflects that while medical providers wait for an opportunity to have their
respective cases heard by an ALJ, the medical providers’ Medicare revenue payment stream
becomes significantly reduced (Alsan et al., 2019). This not only creates an untenable financial
strain on the medical provider serving underserved communities, but also limits the availability
of community-based medical providers, as they can no longer continue to operate their
businesses and clinics.
Purpose of the Project and Research Questions
Three primary research questions drove this research, given the fundamental knowledge
of the lived experiences associated with health care executive perception, beliefs, and
organizational impacts due to Medicare claim reviewers denying a high number of beneficiary
claims, a small number of those same denied claims being appealed, and a large percentage of
the claims that are appealed being overturned by a higher appellate-level organization within the
Medicare organization (OIG, 2018).
1. What are the beliefs of medical care providers in Medicare’s ability to render accurate
claim approval decisions?

5
2. What is the perception, based on lived experiences of health care professionals, of the
ability of Medicare to meet its mission statement of providing health care to Medicare
beneficiaries?
3. What do health care executives and leaders believe is necessary for Medicare to meet
organizational policies and strategies requiring them to align with the CMS mission
statement to support beneficiaries?
Importance of the Study
CMS recently redesigned the global and professional direct contracting model to advance
administration priorities, including the commitment to advancing health equity, in response to
stakeholder feedback and participant experience (CMS, 2023). CMS’s Innovation Center also
has undertaken an effort to solicit a cohort of participants for the accountable care organization
realizing equity, access, and community health (REACH) model (CMS, 2023). The purpose of
the new model is to encourage health care providers to coordinate care to improve the care
offered to people with Medicare, specifically those from underserved communities (CMS, 2023).
In spite of these aforementioned initiatives, medical providers, Medicare beneficiaries residing in
underserved communities, and the ability of the Medicare program to support its beneficiary
population are significantly and adversely impacted by a number of possible program personnel
inefficiencies. This study relied on purposeful semistructured interviews of executive health care
leaders and clinicians as well as literature research to recommend interventions to address these
inefficiencies. Recommendations touch on factors such as personnel, training, facilities,
equipment and materials, and other identified program inputs.

6
Overview of the Theoretical Framework and Methodology
In this study, I used the Clark and Estes (2008) performance gap analysis framework to
discern the knowledge, motivational, and organizational gaps within the CMS government
bureaucracy. The human causes behind why perceptions and beliefs for the claim denials and
associated MAC claim denial affirmations contrast with OMHA ALJs overturning MAC denial
decisions must be diagnosed, with corresponding efforts to identify appropriate solutions (Clark
& Estes, 2008). Clark and Estes emphasized that different individuals and groups can have very
different beliefs about what makes them effective. MACs operate under contracts worth
hundreds of millions of dollars, which may incentivize the MACs to deny supported medical
provider claims. ALJs conduct fact-based discussions with medical providers about medically
necessary procedures supported by a medical practitioner’s verbal input. The dichotomy of
flawed decision-making between the MACs and the ALJs creates delays across the Medicare
spectrum of claim submissions (Lerman, 2014).
Organization of the Study
The dissertation follows a traditional five-chapter model. Chapter One provides a
synopsis of the Medicare program, eligible beneficiaries, the medical provider-submitted claim
process, and the Medicare approval/denial system and associated appellate review process.
Chapter Two reviews the relevant literature and the conceptual framework for the study. Chapter
Three details the research methodology. Chapter Four provides the results for qualitative
findings and economic impact. Chapter Five details the proposed recommendations.

7
Chapter Two: Review of the Literature
The Medicare program has experienced many changes since its inception in 1965. When
it was established, the primary goal of the program was to ensure that elderly populations (over
the age of 65) throughout the country had adequate, affordable health insurance and
hospitalization care (Meds News, 2021). In 1972, Medicare was expanded to cover younger
patients with specific disabilities and people with end stage renal disease. Medicare plays a key
role in providing health and financial security to more than 60 million elderly people and
younger people who may have disabilities (Kaiser Family Foundation [KFF], 2019). In 2017,
Medicare spending accounted for 15% of total federal spending and 20% of total national health
spending (KFF, 2019).
As of 2017, Part A of the Medicare program is funded primarily by a 2.9% payroll tax on
earnings, with employers and employees each contributing 1.45% (KFF, 2019). The funds are
deposited into the Hospital Insurance Trust Fund. Higher earners with incomes exceeding
$200,000 for single earners and $250,000 for married couples pay a higher payroll tax of 2.35%
(KFF, 2019). Part B of the Medicare program is funded by general revenues and beneficiary
premiums between $135.50 to $460.50 (2019 rates) per person per month (KFF, 2019). Medicare
covers a variety of health care services, including inpatient and outpatient hospital care,
physician services, and prescription drugs. Total Medicare benefit payments in 2017 exceeded
$688 billion (KFF, 2019).
Today, the HHS, with its CMS division, pays 16 MACs over $500 million each, or $8
billion total, to administer the claims processing and first level of appellate review for denied
Medicare claims. MACs process an estimated 1.1 billion Fee-For-Service claims for more than
35 million Medicare beneficiaries (CMS, 2023). They also provide services for more than 1.1

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million health care providers enrolled in Medicare Fee-For-Service who have a number of their
claims denied for payment by Medicare.
The OIG (2019) found that 13% of the requests denied should have been covered by
Medicare. The percentage is higher for Medicare Advantage Plans, or Part C, at 18% or an
estimated 1.5 million payments for all of 2019. The OIG (2019) further reported that only 1% of
all denied beneficiary claims are appealed by the beneficiary or health provider. This study
attempts to evaluate the reasons claim reviewers denied the claims only to have over 70% of
those same claims overturned by the third Medicare appellate-level ALJ. The potential cost
benefits of rectifying the disparities between the first level of appellate review by the MACs and
the third appellate level of review by the ALJs within Medicare’s OMHA is assessed during the
study.
The Role of Medicare in U.S. Culture
President Lyndon B. Johnson signed House Resolution 6675 on July 30, 1965, to
formulate what is now known as Medicare. The Social Security Amendments of 1965 were
formulated in the House Ways and Means Committee and passed the House of Representatives
by a vote of 313–115 (five abstentions) on April 8, 1965 (Social Security Administration, n.d.).
The Senate passed the bill on July 9, 1965, by a vote of 68–21, with 11 abstentions (Social
Security Administration, n.d.). This historic act allowed Americans to start receiving Medicare
health coverage with Medicare’s hospital and medical insurance benefits.
Following its formulation in 1965, the Medicare program has developed into an
increasingly comprehensive national health insurance program designed primarily for people (or
“beneficiaries”) 65 years old or older. Since 1972, beneficiaries under 65 years of age with
certain disabilities and people of all ages with end stage renal disease (permanent kidney failure

9
requiring dialysis or a kidney transplant) have become eligible for Medicare health insurance.
Medicare Part A covers hospital, hospice, and skilled nursing facility care. Medicare Part B
covers doctors’ services, outpatient care, and some home health care. Medicare Part D covers
prescription drugs (Medicare, n.d.). Table 1 illustrates the coverage breakdown.
Table 1
Medicare Coverage
Medicare type Coverage Requires a premium payment
Part A Inpatient care No, paid for through payroll taxes
Part B Doctor services and outpatient care Monthly premium
Part D Prescription drug coverage Monthly premium

10
MACs
MACs were created as private health insurers shortly after the creation of the Medicare
program. They were known as Part A fiscal intermediaries and Part B carriers at that time.
Subsequently, the fiscal intermediaries were renamed MACs in 2003 as a part of Section 911 of
the Medicare Prescription, Improvement, and Modernization Act of 2003 (2003). MACs perform
the following administrative functions:
• processing Medicare Fee-For-Service claims,
• paying and accounting for Medicare Fee-For-Service actions,
• enrolling providers in the Medicare Fee-For-Service program,
• handling provider reimbursement services and auditing institutional provider cost
reports,
• handling claim appellate redetermination requests (first level of appeal),
• responding to provider inquiries,
• educating providers on the Medicare Fee-For-Service billing requirements,
• establishing local coverage determinations,
• reviewing medical records associated with selected claims, and
• coordinating with CMS and other Fee-For-Service contractors.
There are currently three Medicare Part A and B contractors and four durable medical
equipment (DME) contactors for CMS (Episode Alert, n.d.). The MACs service more than 1.1
million health care medical providers enrolled in the Medicare Fee-For-Service program and
process over 1.2 billion Medicare Fee-For-Service claims annually (Episode Alert, n.d.). The 12
regional MACs include Palmetto GBA, National Government Services, Novitas Solutions, and
First Coast Service Operations. The four DME contractors that serve both Part A and B services

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and DME claims are Noridian Healthcare Solutions and CGS Administrators (Episode Alert,
n.d.).
To illustrate the significance of the volume and associated cost of just one of the MAC
contracts, consider the Noridian Healthcare Solutions contract. This contract, which is base year
cost plus award fee with 6 option years, was awarded by CMS on January 1, 2021 (CMS, 2020).
The estimated value of this single contract (out of the 16 total MAC contracts) to Noridian
Healthcare Solutions is $556,805,519 (CMS, 2020). The contract will service more than 470
hospitals, nearly 124,000 physicians, and almost 4 million Medicare beneficiaries. Noridian
accounts for approximately $38 billion in the payout of Medicare A and B benefits, or nearly
10% of the total national benefit expenditures. The Medicare program has a far-reaching impact
on the healthy lives of millions of elderly Americans.
Impact on the Elderly—What Health Concerns Are Addressed and Covered
The Administration on Aging is the principal agency of the HHS designated to conduct
the provisions of the Older Americans Act of 1965 and its amendment as the Supporting Older
Americans Act of 2020 (Administration for Community Living, 2023; Older Americans Act of
1965, 1965; Supporting Older Americans Act of 2020, 2020). The Administration on Aging is an
agency in the HSS providing leadership and expertise on programs, advocacy, and initiatives
affecting older adults and their caregivers and families. The original Older Americans Act of
1965 established the Administration on Aging’s authority to provide grants to states for
community planning and social services, research and development projects, and personnel
training in the field of aging (Administration for Community Living, 2022). The law also
established the Administration on Aging to administer newly created grant programs and to serve
as the federal focal point on matters concerning older Americans.

12
Although older Americans may receive services under many other federal programs, the
Older Americans Act is considered a significant mechanism enabling the organization and
delivery of social and nutrition services to elderly Americans and their caregivers
(Administration for Community Living, 2022). The Supporting Older Americans Act of 2020
also authorized a wide array of service programs through a national network of more than 56
state agencies on aging, 618 area agencies on aging, nearly 20,000 service providers, 281 tribal
organizations, and one Native Hawaiian organization representing 400 tribes (Administration for
Community Living, 2022). The act also includes community service employment for lowincome older Americans; training, research, and demonstration activities in the field of aging;
and vulnerable elder rights protection activities.
The income levels of elderly patients also contribute to a lack of adequate health care for
elderly patients. Joe et al.’s (2015) analyses of health care utilization in India revealed that
income played a significant role in diverting the distribution of health care away from the poor
elderly. The study demonstrated that the impact of income on utilization is best reflected at the
economic level, as populations with higher per capita incomes have higher elderly health care
utilization even when the levels of need-predicted distribution across population sectors are
found to be similar. In addition, the distribution of health care among the elderly in various social
groups and with educational accomplishments favors the wealthy and contributes to inequality
for the poor. Joe et al. recommended public investments in health care infrastructure
emphasizing geriatric care in rural areas and underdeveloped regions to increase access and
quality of health care for the elderly. Yet even with the increase of health care infrastructure,
medical students need to overcome negative stereotypes associated with elderly patients.

13
Dobrowolska et al. (2019) conducted a multimethod study involving triangulation and
found that the conceptualization of old age reported by seniors and medical students primarily
projected negative connotations. The negative connotations were based upon stereotypes within
society regarding the elderly. Old age was perceived by groups of participants as having (a)
positive, (b) negative, and (c) neutral connotations. The negative connotations predominated the
findings. The beginning of old age was defined by the metric of age and was described by
showing the complexity of the aging process involving subjective, objective, and societal
aspects. The study participants included a purposeful sample of individuals aged 65 and over (n
= 80) and medical and nursing students (n = 100) in the eastern region of Poland (Dobrowolska
et al., 2019). Experience of age discrimination in health care institutions was reported by 24
(30%) of seniors and witnessed by 47 (47%) students surveyed; for both groups, the bias
occurred mainly in a hospital setting, from physicians. Only 48 students (48%) declared a
willingness to collaborate with older people in the future, and barriers were reported at the
personal and professional levels, and also in the perceptions of older people. Dobrowolska et al.
study concluded there is a need for ethical education within medical and nursing courses to shape
positive and equitable attitudes toward the elderly, combined with a comprehensive process of
medical cultural immersion by student medical practitioners.
Vulnerable and low-income elderly Americans can be susceptible to internalized negative
stereotypes that adversely impact an elderly person’s physical health, mental health, and overall
well-being. Barney et al. (2016) stated that ageist beliefs and stereotypes can interfere with
health care seeking as well as with the diagnosis and the treatment recommendations older
patients receive from medical providers. Gullette (2004) posited that younger people see elders
as being an unproductive drain on critical resources. Elderly Americans cannot reduce the

14
negative impact of ageism until it becomes visible. Nemmers (2004) stated health care providers
and students need to be taught about the concepts and symptoms of ageism of elderly Americans.
They should be taught that ageism is unethical and unacceptable (Bowling, 1999). Specifically,
O’Brien and Whitbourne (2015) suggested that assertiveness and stress-management training
may be taught by nurses, health educators, social workers, or psychologists to help the elderly
understand medical options and to optimize positive self-perceptions in their interactions with
medical providers.
North and Fiske (2012) stated positive self-perceptions benefit physical health and wellbeing. Positive self-perceptions combined with finding ways to have respectful interactions with
people with or suspected of having disabilities, to include age-related issues, can improve elderly
mental and physical health (Van Egeren, 2004). There are impediments to instilling positive selfperception, as access to health care services and the quality of services are politically influenced
by policymaker priorities and bias (Travis et al., 1995). Public policy initiatives are needed to
reduce barriers to health care access for low-income rural and inner-city-dwelling older women
(Dan et al., 1994), specifically for the barriers most often reported by older women of color
(Fitzpatrick et al., 2014). Woman of color are the largest proportion of low-income elders in the
United States (Gullette, 2004).
Effects of Race and Cultural Competence
In addition to the research findings associated with elderly woman of color, George and
Jackson (1998) found that in a study of elders’ attitudes toward and experiences with physicians,
European Americans were significantly more likely than African Americans to agree that doctors
do their best to allay patients’ worries and always treat them respectfully. Alsan et al. (2019)
conducted a randomized trial in Oakland, California, to examine the effect of diversity of the

15
physician workforce on the demand for preventative care among African American men. Alsan
et al. found that when patients and doctors had a chance to meet in person, Black patients
assigned to a Black doctor increased their demand for preventive care. The proclivity of Black
patients to align themselves with physicians of a similar race aligns with several studies reporting
that ethnic minority doctors are more likely than White doctors to work in underserved areas and
see patients who share their racial backgrounds (Cantor et al., 1996; Komaromy et al., 1996;
Moy & Bartman, 1995; Walker et al., 2012). Cultural health resources may assist providers in
understanding the need for demographic alignment with their patients.
The Office of Minority Health within the HHS has created training materials at the
national level recognizing the growing concerns about racial and ethnic disparities in health and
the need for health care systems to accommodate increasingly diverse patient populations (Office
of Minority Health, 2002). The cultural health resources provide health care professionals with
information, continuing education opportunities, and resources to learn about and implement
various cultural health standards. The resources include cultural competency and cultural
humility, combating implicit bias and stereotypes, and other forms of effective cross-cultural
communication skills.
Cultural competence (Betancourt et al., 2003) among America’s medical community
professionals has become a national concern for policymakers. The Office of Minority Health
has focused on three major areas of health research to provide a context that addresses the
importance of culturally competent care as a part of their National Standards for Culturally and
Linguistically Appropriate Services. The areas include health disparities, access to health care,
and quality of care. The Office of Minority Health (2001) created 14 standards:

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1. “Health care organizations should ensure that patients/consumers receive from all
staff members effective, understandable, and respectful care that is provided in a
manner compatible with their cultural health belief and practices and preferred
language” (Office of Minority Health, 2001, p. 7).
2. “Health care organizations should implement strategies to recruit, retain, and promote
at all levels of the organization a diverse staff and leadership that are representative of
the demographic characteristics of the service area” (Office of Minority Health, 2001,
p. 8).
3. “Health care organizations should ensure that staff at all levels and across all
disciplines receive ongoing education and training in culturally and linguistically
appropriate service delivery” (Office of Minority Health, 2001, p. 9).
4. Health care organizations must provide timely “language assistance services,
including bilingual staff and interpreter services, at no cost to each patient/consumer
with limited English proficiency at all points of contact” (Office of Minority Health,
2001, p. 10).
5. “Health care organizations must provide to patients/consumers in their preferred
language both verbal offers and written notices informing them of their right to
receive language assistance services” (Office of Minority Health, 2001, p. 11)
6. Health care organizations must assure the competence of language assistance
provided to limited English proficient patients/consumers by interpreters and
bilingual staff,” rather than relying on a patient’s family and friends (Office of
Minority Health, 2001, p. 12).

17
7. “Health care organizations must make available easily understood patient-related
materials and post signage in the languages of the commonly encountered groups
and/or groups represented in the service area” (Office of Minority Health, 2001, p.
13).
8. “Health care organizations should develop, implement, and promote a written
strategic plan that outlines clear goals, policies, operational plans, and management
accountability/oversight mechanisms to provide culturally and linguistically
appropriate services” (Office of Minority Health, 2001, p. 14).
9. “Health care organizations should conduct initial and ongoing organizational selfassessments” of culturally and linguistically appropriate activities “and are
encouraged to integrate cultural and linguistic competence-related measures into their
internal audits, performance improvement programs, patient satisfaction assessments,
and outcomes-based evaluations” (Office of Minority Health, 2001, p. 15).
10. “Health care organizations should ensure that data on the individual
patient’s/consumer’s race, ethnicity, and spoken and written language are collected in
health records, integrated into the organization’s management information systems,
and periodically updated” (Office of Minority Health, 2001, p. 16).
11. “Health care organizations should maintain a current demographic, cultural, and
epidemiological profile of the community as well as a needs assessment to accurately
plan for and implement services that respond to the cultural and linguistic
characteristics of the service area” (Office of Minority Health, 2001, p. 17).
12. “Health care organizations should develop participatory, collaborative partnerships
with communities and utilize a variety of formal and informal mechanisms to

18
facilitate community and patient/consumer involvement in designing and
implementing” culturally and linguistically appropriate activities (Office of Minority
Health, 2001, p. 18).
13. “Health care organizations should ensure that conflict and grievance resolution
processes are culturally and linguistically sensitive and capable of identifying,
preventing, and resolving cross-cultural conflicts or complaints by
patients/consumers” (Office of Minority Health, 2001, p. 19).
14. “Health care organizations are encouraged to regularly make available to the public
information about their progress and successful innovations in implementing the . . .
standards and to provide public notice in their communities about the availability of
this information” (Office of Minority Health, 2001 p. 20).
Studies referenced by the Office of Minority Health (2001) align with other studies that support
the idea that culturally competent services can potentially improve the health of minorities by
improving physician–patient communication and the delivery of health care (Vermeire et al.,
2001).
In another study, Cook et al. (2005) assessed satisfaction of ethnic minority community
members in Omaha, Nebraska, with the care received and cultural competency of health care
providers. The researchers sought input from Omaha ethnic minority communities on how to
improve the care they received and asked the participants of the study why they did not
participate in health care research. The 72 survey participants included African American,
Hispanic, Native American, Sudanese, and Vietnamese individuals, as well as eight European
Americans. The results of the study reflected that the majority of the respondents were satisfied

19
with the care they received, but for a small percentage, language, communication, or culture
contributed to dissatisfaction (Cook et al., 2005).
Some respondents did not think their medical provider was culturally competent (Cook et
al., 2005). In the Cook et al. (2005) study, cultural competency was defined by the respondents
as the provider not being sufficiently knowledgeable about the respondents’ racial, ethnic, or
cultural background. In addition, some participants indicated that they preferred a provider of
similar racial, ethnic, or cultural background, or they thought some diseases were better treated
by a provider of the same racial, ethnic, or cultural background. Irrespective of respondents’
views related to the cultural competency of the provider, an overwhelming majority of the study
respondents, excluding African Americans, indicated a willingness to participate in health care
research. In conclusion, Cook et al. found that satisfaction with health care providers was not
associated with perceived cultural competency and that the cultural competency of the provider
did not affect patient willingness to participate in health care research; however, the Hawthorne
effect might have been in operation.
The Hawthorne effect is named after the location of experiments conducted at Western
Electric’s Hawthorne Works electric company in Illinois (Gillespie, 1991). The purpose of the
study was to examine the effect of various factors within a work environment, such as lighting,
break timing, and workday length, on worker productivity (Gillespie, 1991). While the study was
being conducted, the question arose as to whether the economic determinants of worker motives
and their grasp of the industrial environment were downplayed by previous researchers (Mayo,
1933). Gillespie (1991) concluded that researchers need to take into account the possibility that
research participants may unwittingly give responses based on what they expect the researcher to
hear or affected by the act of being observed.

20
To further accentuate the need to combat the effects of racism through cultural immersion
medical education programs, Nuriddin et al. (2020) posited that inequities in health care can be
illustrated in a variety of studies. Inequitable health care in the United States is marked by racial
injustice and a myriad of forms of violence (Nuriddin et al., 2020). Injustice within the health
care sector can be attributable to unequal access to health care, the segregation of medical
facilities, and the exclusion of African Americans from medical education (Nuriddin et al.,
2020). Society within the United States unfairly targeted ethnic minority populations for
compulsory sterilization during the 1920s. Once challenged in court (Buck v. Bell, 1927), Carrie
Buck, a young White woman who was institutionalized after being raped and impregnated, was
ruled against by the Supreme Court for being eugenically unfit. California had the largest
sterilization program, with nearly 15,000 people sterilized by 1942 (Nuriddin et al., 2020).
Between 2006 and 2010, 144 incarcerated women were illegally sterilized. Twenty-four percent
were Black women, and 37% were Latinas (Nuriddin et al., 2020). Nuriddin et al. posited that
inequities in housing, employment, education, and access to and quality of health care continue
to shape racial health inequities. Du Bois and Eaton (1899/1996) discussed structural
explanations by addressing social determinants such as environmental, political, and
socioeconomic circumstances that lead to poor health. Therefore, age and race do appear to
significantly contribute to diminished health care within underserved and ethnic minority
populations, which is worrisome, as projections indicate a significant increase in ethnic minority
populations.
The Medicare Program and Claim Submission Process
National projections from U.S. Census Bureau researchers have suggested that the
population of the United States, currently at 339,996,563, will grow to nearly 400 million people

21
by 2058 (Vespa et al., 2020). More specifically, the number of people aged 65 and older is
projected to increase to over 69 million in 2030 or approximately 20% of the U.S. population
(U.S. Census Bureau, 1996). For comparative purposes, in 2000, 82% of the total U.S.
population was White, 13% Black, 4% Asian or Pacific Islander, and the remaining 1% Native
American. People of Hispanic ethnicity comprised approximately 11% of the population. By
2050, 75% of the U.S. population is predicted to be White, 15% Black, and 9% Asian or Pacific
Islander (U.S. Census Bureau, 1996). Further, the Hispanic population is expected to increase to
25%, while the non-Hispanic White population is expected to decline to 53%.
An efficient and equitable Medicare claims processing system can be critical to ensuring
that minority and underserved populations of the United States receive medically necessary
medical treatments. The Medicare program (CMS, 2023) is a federal health insurance program
for people who are 65 years of age or older, designated younger people with disabilities, and
people with end stage renal disease requiring dialysis or a transplant.
As indicated previously, Medicare-related policy decisions can create unintended
consequences for underserved populations (Thrall, 2011). Spending for Medicare and Medicaid
exceeds more than 23% of the federal budget (Thrall, 2011). The White House 2022 federal
budget attempted to reform Medicare payments to insurers and certain providers to reduce
overpayments and strengthen incentives to deliver value-based care in an effort to extend the life
of the Medicare Trust Fund, lower premiums for beneficiaries, and reduce overall federal costs
(Office of Management and Budget, 2021). Thrall (2011) enumerated the following major
reasons for unintended consequences: a failure to appreciate the complexity of the issues, the
open-ended nature of medical advances with attendant increases in costs, the inducement of

22
change in behaviors in response to legislation, and the moral hazard of people spending other
people’s money.
Only 1% of denied Medicare claims are appealed, and of that 1%, over 70% are
overturned by an ALJ at the third appellate level (there are five levels of appeal) within the
denied-claim appeals process (OIG, 2018). MACs are typically the first line of the medical
provider-submitted Medicare claim review process for payment approval. Since 1966, MACs
have reviewed millions of claims and have a denial rate that far exceeds 50% of the submitted
claims for certain categories of claims (e.g., peripheral vascular deficiency). The denied claims
adversely affect the payment of claims for necessary medical treatment of millions of elderly
beneficiaries (OIG, 2018).
Problem of Practice
The intent of this research was to obtain and evaluate the collective anecdotal inputs
relating to issues associated with Medicare claims processing from the lived experiences of
health care executives. Medicare organizational claim reviewers are denying submitted provider
Medicare claims at an 18% or more denial rate, where only 1% are challenged (appealed), and of
those 1% challenged, 70% are overturned (at a significant financial burden to the challenging
party) by a Medicare third-level appellate ALJ. The Clark and Estes (2008) performance gap
analysis framework was used to explore the knowledge, motivational, and organizational gaps
according to the perceptions of executive health care leaders for prepared claims submitted by
their health care provider organizations. Health care executives and leaders were interviewed
individually and coded according to their age, race, gender, supervisory status, and time of
service in their positions.

23
Health care provider organizational leaders and supervisors also can help reduce
employee stress and burnout by providing employees with decision-making opportunities and
offering them social support (Miller et al., 1990). In a book popular with professional
communicators, Larkin and Larkin (1994) argued that the time it takes employees to understand
and implement change could be reduced by empowering supervisors to communicate the change,
relying on face-to-face communication as the primary channel for conveying change
information, and communicating the relevant performance and impact of change on the local
work unit.
Supervisors also play a key role in strengthening organizational identification. Myers and
Kassing (1998) concluded that organizational identification was linked with supervisors who
were seen as competent communicators and who also provided more interactive involvement.
Scott et al. (1999) found that employee communication and organizational identification
contributed to retention. Employees who experienced favorable relationships with their
supervisors and who felt they were well informed and listened to were less likely to leave the
organization. More recently, Madlock’s (2008) survey of Midwest employees found that a
supervisor’s communication competence was the greatest predictor of employee satisfaction.
In a subsequent study of the culture of learning organizations, Joo et al. (2012) came to
similar conclusions, positing that a culture that valorizes continuous learning, dialogue and twoway communication, empowerment, team learning, and strategic leadership facilitates change
management. A national survey by the Families and Work Institute (Galinsky et al., 1996) found
that an open communication environment was the single most important quality that prospective
employees sought in a workplace environment. Smidts et al. (2001) found that organizational
identification also increases in an open communication climate where employees can speak up,

24
be heard, and participate in organizational discussions. Smidts et al. concluded that the way an
organization communicates internally is more important than what messaging is communicated
in terms of building organizational identification.
Berger (2015) referenced studies indicating that organizations with engaged and
committed employees were 50% more productive than those organizations where employees
were not engaged, and employee retention rates were 44% higher in organizations with engaged
employees (Izzo & Withers, 2000). Significant improvements in communication effectiveness in
organizations were linked to a 29.5% rise in market value (Watson Wyatt, 2004). In addition,
companies with highly effective employee communications outperform companies with less
effective communications—one study showed that they produced 20% less turnover and 47%
higher shareholder returns (Watson, 2010).
Supervisors and their employee relationships can have a significant impact on Medicare
claim reviewer approval or denial decisions. The U.S. Medicare Advantage Program deniedclaims appellate submission processes adversely affect underserved populations. The OIG (2018)
reported that their MACs (e.g., Noridian Healthcare Solutions) had 75% of their own providersubmitted claims denials overturned between 2014 and 2016. The number of Medicare
Advantage Program beneficiaries has increased from 8 million in 2007 to over 21 million
beneficiaries in 2018 (OIG, 2019). As of 2019, Black, Hispanic, and other non-White
beneficiaries over the age of 65 accounted for approximately 32% of the total number of
Medicare Advantage Program beneficiaries (CMS, 2019). The CMS arguably recognizes the
significant adverse impact it is having on its beneficiary populations when its MACs deny such a
significant percentage of claims (Lerman, 2014). CMS instituted an inequitable system that
adversely impacts medical provider revenue streams, precluding them from operating their

25
practices within underserved populations. CMS’s inequitable environment limits medically
necessary care and treatment for underserved populations when they do not have an available
medical practitioner who shares a common demographic (Alsan et al., 2019). Theoretically, if
the 1% of denied claims by the MACs that are appealed were extended to the entire universe of
all submitted claims that are ultimately overturned, the impact could be considered a
humanitarian crisis within the U.S. health care community and the potential cost savings
colossal.
A research scientist at the University of Southern California’s Schaeffer Center for
Health and Policy and Economics, Ritka Chaturvedi, is a primary collaborator on an initiative to
ensure that all communities have access to its Medicare benefits (Chaturvedi et al., 2023). The
American Life in Realtime longitudinal survey used wearable data collected from a
representative population of adults to evaluate the dynamic interplay between factors such as
social and structural determinants and health outcomes. The factors were evaluated particularly
within underserved and marginalized communities (Chaturvedi et al., 2023). The American Life
in Realtime selected study cohort (N = 1,038) was inclusive of the U.S. adult population across
demographic, socioeconomic, and health factors. The external factors the study assessed were
physical environment, social environment, and economic environment. Intrinsic factors assessed
included demographics and personality, health behaviors, and health outcomes. The probability
sampling used in the Chaturvedi et al. (2023) study improved the accuracy and validity of
population inference and leveraged a large-scale sample from the Understanding America Study
(University of Southern California Dornsife, n.d.). Specifically, to address lower participation
among historically marginalized groups, the study oversampled people who were Black,

26
American Indian, Alaska Native, Hawaiian or Pacific Islander, mixed race, and Hispanic, as well
as people whose education was lower than a bachelor’s degree.
Theoretical Framework
As previously noted, I used the Clark and Estes (2008) performance gap analysis
framework to discern the health care leaders’ knowledge, motivational, and organizational gaps
within the CMS government bureaucracy. The human causes creating identifiable disparities
between the claim denials and associated MAC claim denial affirmations, contrasted with
OMHA ALJs overturning MAC denial decisions, must be diagnosed with corresponding efforts
to identify appropriate solutions.
Clark and Estes (2008) emphasized that different individuals and groups can have very
different beliefs about what makes them effective. MACs operate under contracts worth
hundreds of millions of dollars, which may incentivize the MACs to deny supported medical
provider claims. ALJs, conversely, conduct fact-based discussions with medical providers on
medically necessary procedures supported by a medical practitioner’s verbal input. The
dichotomy of flawed decision-making between the MACs and the ALJs creates delays across the
Medicare spectrum of claim submissions (Lerman, 2014). Figure 1 illustrates the gap analysis as
it relates to the study. These dichotomies within CMS claim processing divisions may be a
contributing factor or added ambiguity in a health care executive or leader’s ability to submit
satisfactory Medicare claims for medically necessary beneficiary treatments.

27
Figure 1
Gap Analysis of Health Care Executive Perceptions of Medicare Claim Processing
Note. Framework based on Turning Research Into Results: A Guide to Selecting the Right
Performance Solutions, by R. E. Clark and R. Estes, 2008, Information Age Press.
Purpose of the Study
The purpose of the study was to obtain and evaluate the collective anecdotal inputs relating to issues associated
with Medicare claims processing from the lived experiences of health care executives. The Clark and Estes (2008)
gap analytical framework was used to examine the health care executive’s lived experience, knowledge, motivation,
and the organizational factors for Medicare claim submissions. The self-efficacy theory provided elucidation in
evaluating these factors.
Clark and Estes (2008) Gap Analysis
Framework
Health Care Executive/Leaders’ Knowledge
Declarative
Procedural
Health Care Executive/Leaders’ Motivation
Self-Efficacy
Health Care Executive/Leaders’ Organization
Resourcing
Training
Institutional Conceptualization
Research Questions
1. What are the beliefs of medical care providers in
Medicare’s ability to render accurate claim approval
decisions?
2. What is the perception, based on lived experiences of
health care professionals, of the ability of Medicare to
meet its mission statement of providing health care to
Medicare beneficiaries?
3. What do health care executives and leaders believe is
necessary for Medicare to meet organizational policies
and strategies requiring them to align with the CMS
mission statement to support beneficiaries?

28
Underserved communities’ access to health care requires an increased effort on the part
of institutions like CMS to evaluate organizational cultural competence (Delphin-Rittmon et al.,
2021) to reduce its significant backlog of appellate reviews. Cultural competence incorporating a
set of congruent behaviors, attitudes, and policies that align in an agency allowing professionals
to effectively work together is necessary in cross-cultural situations (Lewin Group, 2002).
Congress has apportioned millions of dollars to CMS to reduce the OMHA backlog of appellate
reviews. OMHA planned to hire 80 more ALJs and 600 new staffers over 14 months, permitting
the formulation of 170 ALJ teams (Porter, 2018). Yet the ALJ backlog continues to grow, with
an outstanding Congressional mandate to have the backlog reduced to meet a mandated 90-day
maximum review time for each individual case by the end of Fiscal Year 2022.
Health care industry leaders can argue that the organizational structures of CMS and the
OMHA are diametrically opposed to each other in their respective goals and outcomes. CMS
offers medical providers an opportunity to appeal denied claims on behalf of their beneficiaries
in one of two progressive appellate levels referred to as “redetermination” and “reconsideration,”
respectively (Lerman, 2014, para. 9). CMS contracts these levels of appellate reviews to MACs.
In contrast, the third level of appellate action is addressed directly by HHS OMHA ALJs, not by
CMS contractors, which permits a clinical inference by the medical providers (Lerman, 2014).
An inquiry into the similar and unique decision-making processes of claim reviewers at each
level of review provides a basis for comparative analysis.
To develop descriptive qualitative explanatory questions, independent and dependent
variables must be incorporated into the line of questioning and have a general focus on what
concepts may comprise the outcomes or study factors. Research Question 1 asked, “What are the
beliefs of medical care providers in Medicare’s ability to render accurate claim approval

29
decisions?” The first question in the study addresses the internal and external effects of CMS
Level I (redetermination) and Level II (reconsideration) knowledge-based denial decisions.
Although a peer group review is conducted at these two levels of claims denial reviews, the CMS
medical practitioner may not be a board-certified specialist in the area under contention by an
appellate medical provider. Research Question 2 asked, “What is the perception, based on lived
experiences of health care professionals, of the ability of Medicare to meet its mission statement
of providing health care to Medicare beneficiaries?” The second question aligned with the
motivations of a health care executive to become familiar with Medicare claim submissionsupporting data requirements. MACs receive nearly $500 million dollars annually for dispensing
Medicare funds and auditing, denying, and evaluating provider-submitted claims. Cost-saving
measures possibly incentivized within the MAC operating structure may create an incentive for
claim reviewers to deny otherwise supported medically necessary provider-submitted claims.
Research Question 3 asked, “What do health care executives and leaders believe is necessary for
Medicare to meet organizational policies and strategies requiring them to align with the CMS
mission statement to support beneficiaries?” To answer the third question, health care executives
were asked to personally evaluate the organizational structure of HHS with its subordinate CMS
and OMHA departments, which might be diametrically opposed to each other in terms of desired
outcomes. CMS MACs deny potentially supported provider claims, whereas OMHA ALJs
overturn the large majority of previously denied claims by the MACs. Following an audit, the
U.S. Government Accountability Office (2016) recommended that CMS should provide MACs
with written guidance on a method to accurately calculate and report savings from prepayment
claim reviews. In 2019, CMS updated its claims processing systems to automatically calculate

30
savings from prepayment claims denials in a uniform manner across MACs. This CMS process
permitted CMS and MACs to report savings more accurately.
The submitted claim review adjudication process with each MAC requires an analysis to
ascertain knowledge, motivational, and organizational influences on MAC claim adjudicators in
order to evaluate and reflect on their self-efficacy (Bandura, 1978) in the claim review processes.
Also, a qualitative research and case analysis could help uncover (a) why organizations fail to act
on this research knowledge, and (b) what best practices exist to convince organizational
decision-makers to prioritize attending to the foundation stones (Berger, 2015). Persistent
employee communication issues such as low trust and engagement levels, or high turnover and
absenteeism, are clear symptoms of the long-time crisis of weak foundations for employee
communication that may infect all internal communication initiatives and breed disenchantment,
disengagement, discord, and departure (Berger, 2015).
Any general theory of strategic employee communications would likely include leaders,
supervisors, and organizational culture as fundamental (and multidimensional) independent
variables. Leaders’ words and behaviors greatly influence what employees think, feel,
communicate, and do. They set the overall communication tone in organizations through their
communication style and visibility, which is their first and most basic form of nonverbal
communication (Berger, 2015). Supervisors are the front lines for employee trust, engagement,
development, retention, and empowerment. Through their communicative capabilities and
behaviors, they bear the potential to form powerful personal connections with employees, to
extend that connection to an organization and achievement of its goals, and to mobilize
excitement and engagement among employees. Supervisors can be positive contagions for
change and elevated performance.

31
Culture is the dynamic, constructed context for work, understanding, and meaning
(Berger, 2015). The words and behaviors of leaders and supervisors, along with the type of
communication system they use, exert powerful influences on culture. Any organization can
move toward cultivating a culture of communication—a rich environment for growth, learning,
and shared values—that valorizes two-way symmetrical communication, an open communication
system, and the shared beliefs that work is meaningful, people count and should be treated fairly,
and opportunities to grow and advance are part of the job (Berger, 2015).
Strengthening the foundation for employee communication is important. Employers
increasingly recognize the power of employees as brand advocates and informal
spokespersons—now even employee activists—in the digital age, if they are empowered and
armed with the requisite tools and information (Gaines-Ross, 2014). In addition, a cost-benefit
analysis reviewing the calculus associated with the cost of a claim review for millions of denied
claims as a function of the cost associated with 75% of those same claims being overturned by
the OMHA could yield a significant finding. The potential for government cost savings is
significant, as is the health care benefit to a large number of beneficiaries who have had their
necessary medical treatment and claim denied by the MAC for payments. Evaluation of the
perceived motivational influences affecting Medicare claim reviewer approval and denial
decisions, qualitative reviews, and a concise and well-contrived cost-benefit analysis—the three
layers of this study—provide necessary insights into the significant statistical dichotomy
between the number of Medicare denied claims and the high overturn rate of those same denials
by the Medicare OMHA ALJs.
Importantly, Schein (2017) acknowledged the possibility for distortion and cynicism by
employee management; managers could make unconscious personal assumptions about

32
employee motivations. The unconscious personal assumptions are shared and become part of the
culture of an organization. This potential for unconscious bias was considered as a part of this
study to attempt to discern management perceptions of a lazy workforce versus a highly
motivated work force.

33
Chapter Three: Methodology
The purpose of the study was to obtain and evaluate the collective anecdotal inputs
relating to issues associated with Medicare claims processing from the lived experiences of
health care executives. I used the Clarke and Estes (2008) performance gap analysis framework
to help understand how individual contributors and supervisors decide to approve or deny claims.
As supervisors’ and leaders’ words and behaviors greatly influence what employees think, feel,
communicate, and do (Berger, 2015), their contribution to subordinate decisions to approve or
deny claims may be a factor in the accuracy of the claim review process.
The qualitative review conducted for this study included executive and higher academia
health care industry officials with direct knowledge of the Medicare claims submission process.
A preliminary review and evaluation of existing general medical data for the Medicare Current
Beneficiary Survey (MCBS) electronic data user files (CMS, 2024b) identified beneficiary
demographic information corresponding to specific medical diagnoses from the International
Classification of Diseases Editions 9 and 10. An evaluation of the MCBS data over multiple
years (CMS, 2024b) revealed ailment trends, geographic data, gender, age, and race for reported
MCBS interviewed beneficiaries. A cost-benefit analysis was conducted using Medicare and
HHS OIG-reported data reporting the number of annual submitted claims to Medicare. This
analysis could be accomplished as a percentage of the total number of denied claims for that
same universe of submitted claims, the number and type of associated denial reasons
(administrative vs. medical necessity), the number and type of overturned claims by OMHA
ALJs, and the delta between the number of denied Medicare claims by medical condition
category and the number of ALJ overturned claims for the universe of Medicare denied claims.

34
Research Questions
Research Question 1
What are the beliefs of medical care providers in Medicare’s ability to render accurate
claim approval decisions? This research question drew upon literature on factual, conceptual,
procedural, and metacognitive skills acquisition (Krathwohl, 2002) and outcome expectations
(Bandura, 1997), where health care executives and leaders engage in activities they believe will
result in positive outcomes. Research Question 1 was asked to investigate whether a health care
executive or leader’s professional knowledge is adequate (Merriam & Tisdell, 2016) to allow
confident claim payment decisions leading to the proper preparation and submission of Medicare
claims for subsequent payment.
Research Question 2
What is the perception, based on lived experiences of health care professionals, of the
ability of Medicare to meet its mission statement of providing health care to Medicare
beneficiaries? Pintrich (2003 posited that self-regulated learning is a core conceptual framework
to understand the cognitive, motivational, and emotional aspects of learning. Zimmerman’s
(2000) self-regulated learning model is organized into three phases: forethought, performance,
and self-reflection. In the forethought phase, learners analyze the task, set goals, and plan how to
reach them (Zimmerman & Moylan, 2009). Various motivational beliefs energize the process
and influence the activation of learning strategies in the forethought phase, including selfefficacy, expectations, interest in the task, and goal orientation (Zimmerman & Moylan, 2009).
In the performance phase, learners execute the task and monitor how they are progressing, using
various self-control strategies to stay cognitively engaged and motivated to finish the task. The
performance phase involves seeking help, managing time, and self-monitoring (Zimmerman &

35
Moylan, 2009). In the self-reflection phase, learners assess how they have performed the task,
making attributions about their success or failure. These attributions generate self-reactions that
can positively or negatively influence how the learners approach the task in later performances.
Then the cycle begins again.
Research Question 3
What do health care executives and leaders believe is necessary for Medicare to meet
organizational policies and strategies requiring them to align with the CMS mission statement to
support beneficiaries? Schein (2017) discussed a delineation of how a subordinate is vulnerable
to authority systems within an organization. Specifically, a psychological distance exists between
higher and lower echelons, which Hofstede (1991) referred to as the power distance. Schein
further posited that every group, organization, occupation, and macroculture develops norms
around the distribution of influence, authority, and power.
Overview of Design
The interviewees in this qualitative study were both senior supervisory and executive
health care field officers who possess Medicare claim review experience. The selected
participants had direct responsibility within their respective fields for medical decision-making
analysis regarding the approval or denial of medical provider-submitted claims on behalf of
Medicare beneficiaries receiving authorized medical treatments. The interviewees were
convenience sampled (Merriam & Tisdell, 2016) and purposefully network sampled to permit a
consideration of the time, money, location, availability of the respondents, while allowing the
potential sample size to grow larger as more interviewees were contacted throughout the
interview process (Patton, 2002). Lincoln and Guba (1985) recommended sampling until a point
of redundancy is reached and a decision as to sample size sufficiency is made by the researcher.

36
A minimum sample size of 15 health care executives familiar with Medicare claims was
desirable. To achieve this sample size and composition, I contacted known health care industry
leaders and executives on the internet business platform LinkedIn or directly as they were
identified throughout this process. The interview responses were triangulated through an analysis
of the interview responses, observations, and analysis of available secondary data and artifacts.
Research Design
Dexter (1970) posited that interviewing is the preferred tactic of data collection when it is
cheaper and acquires more data than the use of other tactics. The semistructured and purposeful
research interview questions are reflected in Tables 2–4. The format of the tables was informed
by Brinkman and Kvale (2015).

37
Table 2
Interview Questions for Research Question 1
Research
question
Interview questions Potential probes Key concepts
addressed
1. What are the
beliefs of
medical care
providers in
Medicare’s
ability to
render
accurate claim
approval
decisions?
1. Please elaborate if you as a
medical administrator,
academician or clinician
believe you have sufficient
training on local coverage
determinations, national
coverage determinations,
and medical coding
methodologies.
Is the training
virtual,
classroom, other,
and what is the
frequency? Is
your training
documented?
Knowledge and
skills: factual
(Krathwohl, 2002)
2. Please elaborate on your
knowledge of where you
may locate necessary jobrelated policies, references,
and manuals that align with
the Medicare mission
statement?
Do you regularly
access and/or
review those
references in the
performance of
your job?
Knowledge and
skills: conceptual
(Krathwohl, 2002)
3. Please outline the
procedures you use in your
position to research
Medicare claim-related data
to include techniques,
methods, and steps.
How is the progress
documented, if at
all?
Knowledge and
skills: procedural
(Krathwohl, 2002)
4. Can you please describe
how you use your training
to perform your job.
Is the training
adequate in your
opinion to
evaluate claims
for sufficiency
and adequacy?
Knowledge and
skills:
metacognitive
(Krathwohl, 2002),
interpretive
question (Merriam
& Tisdell, 2016)
Note. Concept sources: “A Revision of Bloom’s Taxonomy: An Overview,” by D. R. Krathwohl,
2002. Theory Into Practice, 41(4), 212–218; Qualitative Research: A Guide to Design and
Implementation (4th ed.), by S. B. Merriam and E. J. Tisdell, 2016, Jossey-Bass.

38
Table 3
Interview Questions for Research Question 2
Research question Interview questions Potential probes Key concepts
addressed
2. What is the
perception, based
on lived
experiences of
health care
professionals, of
the ability of
Medicare to meet
its mission
statement of
providing health
care to Medicare
beneficiaries?
5. Please elaborate on your
confidence in your ability
to evaluate the medical
necessity of a treatment in
your position.
Medical coding,
coverage
determinations,
agency policy
considerations
Motivation (Clark
& Estes, 2008;
Pintrich, 2003),
self-efficacy
(Bandura, 1997)
6. Would you describe your
ability to comprehend a
satisfactory “clean” claim?
If so, why? If not,
why not?
Motivation, selfefficacy
7. Discuss your confidence in
the accuracy of Medicare to
render an accurate claim
approval decision.
If applicable, to
what do you
attribute your
lack of
confidence?
Motivation, selfefficacy
8. Please elaborate if you
believe you have adequate
time to satisfactorily
perform your job as it
relates to working with
Medicare program
personnel.
What
impediments, if
any, do you
encounter in
performing
your job?
Motivation, selfefficacy
Note. Concept sources: Self-Efficacy: The Exercise of Control, by A. Bandura, 1997, W. H.
Freeman; Turning Research Into Results: A Guide to Selecting the Right Performance Solutions,
by R. E. Clark and R. Estes, 2008, Information Age Press.

39
Table 4
Interview Questions for Research Question 3
Research question Interview questions Potential probes Key concepts addressed
3. What do health
care executives
and leaders
believe is
necessary for
Medicare to
meet
organizational
policies and
strategies
requiring them
to align with the
CMS mission
statement to
support
beneficiaries?
9. Please describe the
documented goals for
your organization/
department, such as
timeliness and savings.
Are those goals
documented in
a reoccurring
evaluation
program?
Goals (Clark & Estes,
2008; Gallimore &
Goldenberg, 2001;
Schein, 2017)
10. Can you elaborate on
what incentives are in
place at your
organization to meet or
exceed established
position goals, such as
attaining established
statistical goals?
Do you believe
those incentives
are fair? Why
or why not?
Incentive systems (Clark
& Estes, 2008)
11. Can you elaborate on
your organization’s
motivation for you to
timely and accurately
submit organizational
and/or division
productivity reports?
If disincentivized,
why?
Interest, skill, and utility
value (Clark & Estes,
2008; Gallimore &
Goldenberg, 2001;
Schein, 2017)
12. If you receive a
performance evaluation,
do you believe your
performance evaluations
accurately reflect your
work effort?
Are there any
disincentives or
distractors for
you to optimize
your
productivity?
Devil’s advocate
question (Clark &
Estes, 2008;
Gallimore &
Goldenberg, 2001;
Schein, 2017),
interpretive question
(Merriam & Tisdell,
2016)
Note. Concept sources: Turning Research Into Results: A Guide to Selecting the Right
Performance Solutions, by R. E. Clark and R. Estes, 2008, Information Age Press; “Analyzing
Cultural Models and Settings to Connect Minority Achievement and School Improvement
Research,” by R. G. Gallimore and C. Goldenberg, 2001, Educational Psychologist, 36(1), 45–

40
46; Qualitative Research: A Guide to Design and Implementation (4th ed.), by S. B. Merriam
and E. J. Tisdell, 2016, Jossey-Bass; Organizational Culture and Leadership (5th ed.), by E. H.
Schein, 2017, Wiley.
The Researcher
I am a doctoral candidate at the University of Southern California, a retired military
executive leader, retired U.S. federal agent, former multistate major health care insurer special
investigative unit regional manager, and business entrepreneur. My role as the researcher was to
optimize the overall integrity of the research process, adhere to ethical considerations, protect the
confidentiality of interviewees, and provide a comprehensive analysis of the data collected
during the course of the process (Turcotte-Trembly & McSween-Cadieux, 2018).
Data Sources
Method 1: Data Analysis of MCBS Medicare User Files
The secondary data analysis of data artifacts consisted of Medicare-documented MCBS
data for the previous 5 years (CMS, 2024b). The MCBS consists of a representative national
sample of the Medicare population sponsored by the CMS. The MCBS is designed to aid CMS
in administering, monitoring, and evaluating the Medicare program and provides important
information on beneficiaries that is not otherwise collected through operational or administrative
data on the Medicare program.
The MCBS is a continuous, multipurpose longitudinal survey representing the population
of beneficiaries aged 65 and older and beneficiaries younger than 65 with certain disabling
conditions and residing in the United States. The MCBS has conducted continuous data
collection since 1991, completing more than 1.2 million interviews. The MCBS collects this

41
information in three data collection periods, or rounds, per year. Interviews have traditionally
been conducted in person in households and facilities using computer-assisted personal
interviewing. However, due to the COVID-19 pandemic, data collection switched to phone-only
interviews in March 2020 and continued this way throughout most of 2021, with a gradual return
to some in-person interviewing beginning in November 2021. The MCBS, which is sponsored by
the CMS Office of Enterprise Data and Analytics through a contract with the National Opinion
Resource Center at the University of Chicago, releases two limited data set files annually as well
as an annual MCBS chartbook of key estimates from the survey (CMS, 2024b). The 2021 public
use file corresponding to the MCBS sampled 11,387 non-Hispanic and 1,396 Hispanic
beneficiaries, including men and women under the age of 65 through those over the age of 75 for
a total survey size of 12,783. The topic areas covered included quality of patient experience,
access to care, preventative care, cost and utilization, health behaviors or social determinants of
health, health status and functioning, and housing characteristics.
The 2021 Medicare chartbook reflects that among Medicare beneficiaries living only in a
designated community, less than 10% of respondents reported being “very dissatisfied” with
their Medicare-related care. Approximately 50% were satisfied with their general care. Of the
sampled population, over 50% of surveyed respondents were between 65 and 74 years of age
(CMS, 2021). The overall health status among all Medicare beneficiaries surveyed for 2021 is
reflected in Figure 2 (CMS, 2021).

42
Figure 2
Health Status Among All Medicare Beneficiaries, 2021
Note. Reprinted with permission from Health Status Among All Medicare Beneficiaries, 2021, by
Centers for Medicare and Medicaid Services, 2021 (https://chartbook.mcbs.org/#beneficiaryhealth). Copyright 2021 by the Centers for Medicare and Medicaid Services.
Method 2: Qualitative Methods Interviews
The second method involved qualitative interviews. A combination of observation,
copious notetaking, categorical coding, semistructured purposeful interviews, and interview
response analysis was used with the assistance of the computer-based qualitative analysis
software ATLAS.ti 4.2. Related to qualitative data collection, Patton (2002) discouraged the use
of “why” questions to limit speculation about causal relationships.

43
Sample and Population
Each interview was conducted as a part of a face-to-face Zoom (videoconference) call.
The face-to-face call enabled the researcher and participant to establish a rapport (Merriam &
Tisdell, 2016). It also allowed me, as the researcher, to assess participant visual cues (Busher &
James, 2012). The interview introduction was read to each participant, who was also asked to
permit a recording of the interview to provide assist with accuracy during the subsequent
transcription of the interview. I took copious notes during the course of the interview and
conveyed efforts to maximize the confidentiality by identifying each participant only by
consecutive interview numbers.
The interview used a semistructured format to permit flexibly worded interview
questioning (Merriam & Tisdell, 2016). Although 12 open-ended questions were planned for
each participant, flexibility in asking for clarification or expanded questions provided latitude to
allow participants to elaborate on their respective responses throughout the interview process
(Patton, 2002). The 12 open-ended questions each aligned with one of the three research
questions as well as with Clark and Estes’s (2008) performance gap analysis research into
knowledge, motivational, and organizational gaps.
The study’s sampling goal of 15 participants was not attained because 38 identified and
contacted Medicare claim reviewers were unwilling to participate in the study. As a logical
alternative course of action to identify health care industry executives and leaders, health care
leaders who were not known to the researcher were identified through personal associations.
Eight participants volunteered to participate in the study. Demographic information for each
participant is identified in Table 5.

44
Table 5
Study Participant Demographic Information
Participant Gender Role/title Industry status Years of experience
1 Male Emergency room case
management director
Hospital
administration
30
2 Male Chief medical officer Health care provider
system
27
3 Male Biomedical engineer Sleep center 18
4 Male University educator University medical
Education
20
5 Female Director of oncology
department
University medical
education
29
6 Female Medical learning
director
Medical health care
system
35
7 Male Medical practitioner and
surgeon
Surgical clinic 30
8 Female Vice-president of
hospital operations
Nonprofit medical
care
13
Instrumentation
The interview protocol incorporated the organizational (CMS) mission statement and
research questions. The protocol included a type of respondent and interviewee introduction, the
semistructured interview questions, and a conclusive statement (see Appendix).
Data Collection
The MCBS data were collected from expansive MCBS data user files covering a period
of 5 years (CMS, 2024b). The data were collected online and stored on a separate independent
thumb drive marked according to the topic area. The interview with each participant was
conducted over either a Zoom call or telephone call for approximately 60 min and was recorded

45
unless objected to by the respondent. The cost-benefit analysis was conducted using acceptable
economic and financial analysis standards.
Data Analysis
As previously stated, the data collection method of choice was a consensual recorded
interview with copious notetaking. The method of triangulation, according to Patton (2002),
increases the quality and credibility of the data. Triangulation promotes validity and reliability
(Merriam & Tisdell, 2016). Also, four types of triangulation—the use of multiple methods,
multiple sources of data, multiple investigators or triangulating analysts (Patton, 2002), and
multiple theories to confirm any emerging findings—were used as a part of this study (Denzin,
1978; Hovland, 1978).
Method 1: Data Analysis of MCBS User Data Files
MCBS is a publicly accessible database (CMS, 2024b). The MCBS is an ongoing survey
designed to learn more about the people who are covered by Medicare. MCBS data help
legislators and policy makers understand the health care needs and utilization of Americans
covered by Medicare. MCBS data are also used to improve the Medicare program. The MCBS is
an invaluable source of information for administering, monitoring, and evaluating the Medicare
program. For example, data from the MCBS have been used to inform many enhancements to
Medicare coverage, including the creation of new benefits such as Medicare’s Part D
prescription drug benefit. The CMS oversees the Medicare program and sponsors this survey.
CMS is part of the HHS. CMS contracts with the National Opinion Resource Center at the
University of Chicago to conduct the MCBS. The National Opinion Resource Center engages in
sampling, data collection, data processing, and data delivery as part of conducting the MCBS.
MCBS started collecting data in 1991. More than 1.2 million interviews have been conducted,

46
and over 140,000 Medicare beneficiaries have participated in the MCBS since its inception
(CMS, 2024b).
Method 2: Qualitative Interviews of Health Care Industry Executives
Copious handwritten notes and associated interview recordings were reviewed, analyzed,
and coded according to respondent demographics and employee position to categorize responses
from the participants. Eight executives were interviewed. Transcriptions were entered into
qualitative analysis software and coded.
Validity and Reliability
The trustworthiness of the data received from the interviewees was based on the
specificity of the reliable and valid questions posed to the health care industry executive. The
data collection method of choice was a consensual recording with copious notetaking. The
method of triangulation, according to Patton (2002), increases the quality and credibility of the
data. Triangulation promotes validity and reliability (Merriam & Tisdell, 2016). As stated
previously, Hovland (1978) posited four types of triangulation: the use of multiple methods,
multiple sources of data, multiple investigators or triangulating analysts (Patton, 2002), and
multiple theories to confirm any emerging findings as a part of the research.
A benefit-cost ratio analysis derived from a simple adaptation from a net present value
metric was used to analyze the difference between present value benefits and costs using the
formula shown in Equation 1, with BCR = benefit-cost ratio and PV = present value:
BCR = BPV
CPV
A benefit-cost ratio that is greater than 1 is a ratio where the benefits exceed the cost.
Interventions reflecting higher benefit-cost ratios are preferred, whereas interventions reflecting
benefit-cost ratios less than 1 should not be considered for continuance (Levin et al., 2018).

47
Ethical Standard
Issues relating to positionality and power are important considerations in an active
research study. Specifically, Probst and Berenson (2014) posited that the researcher must
understand their influence on what is being studied and the analysis of data; simultaneously, the
research process directly affects the researcher. My experience within the health care industry
and within the U.S. government investigating health care fraud was considered in this study; yet,
the research process also included objective data collection and evaluation criteria for the
conduct of the study. The study’s research design, various Instruments, and articulable
procedures were submitted for ethical, procedural reviews and approval by the institutional
review board before data collection commenced. The institutional review board confirmed
adherence to established ethical guidelines and standards outlined in Sieber (1992).
Limitations and Delimitations
The anticipated limitations included access to and willingness of the prospective
interviewees as well as truthfulness in their responses. Although Zoom (videoconference) calls
were preferred to interview each participant, the researcher had to permit telephone-call-only
interviews in some cases, in order to ensure the respondent could be interviewed as a part of the
study. Also, respondents could choose not to provide certain personal biographical data. I
ensured a reflexive mindset throughout the duration of the study to be conscious of my beliefs,
biases, and assumptions and how they might influence the research process and any derivative
findings (Creswell & Miller, 2000).

48
Chapter Four: Findings
The purpose of the study was to obtain and evaluate the collective anecdotal inputs
relating to issues associated with Medicare claims processing from the lived experiences of
health care executives. This gap analysis research study investigated current health care industry
and higher academia executives’ and leaders’ knowledge, motivations, and organizational
influences affecting their perceptions of their ability to prepare and submit accurate providersubmitted claims. Three research questions guided the research:
1. What are the beliefs of medical care providers in Medicare’s ability to render accurate
claim approval decisions?
2. What is the perception, based on lived experiences of health care professionals, of the
ability of Medicare to meet its mission statement of providing health care to Medicare
beneficiaries?
3. What do health care executives and leaders believe is necessary for Medicare to meet
organizational policies and strategies requiring them to align with the CMS mission
statement to support beneficiaries?
The study considered an economic component of CMS’s impact from a historical and a
cost-benefit analysis perspective. An OIG (2018) report indicated that MACs (e.g., Noridian
Healthcare Solutions) had 75% of their own provider-submitted claims denials overturned
between 2014 and 2016. The number of Medicare Advantage Program beneficiaries has
increased significantly in enrollment, from 8 million in 2007 to over 21 million in 2018 (OIG,
2019). As of 2019, Black, Hispanic, and other non-White beneficiaries over the age of 65
accounted for approximately 32% of the total number of Medicare Advantage Program
beneficiaries (CMS, 2019).

49
The CMS arguably recognizes the significant adverse impact it is having on its
beneficiary populations when its MACs deny such a significant percentage of claims (Lerman,
2014). CMS continues to support an inequitable system that adversely impacts medical provider
revenue streams, precluding these providers from operating their practices within underserved
populations. CMS’s inequitable environment limits medically necessary care and treatment for
underserved populations when they do not have an available medical practitioner who shares a
common demographic (Alsan et al., 2019).
MACs are paid approximately $100 billion each year to administer the Medicare
program. The MACS account for a high percentage of the initial denial of provider-submitted
claims out of the hundreds of billions of dollars in claims submitted each year. Only 1% of that
total universe of denied claims are appealed by medical providers, which may cost an appellate
provider more than $100,000 at the first level of appeal (there are five levels of appeal).
A report published by the OIG (2018) revealed that for those providers who can afford to
proceed to the third level of appellate review by an ALJ in the OMHA, over 75% of those
Medicare Advantage Program denied claims are overturned. A comparative analysis of those
statistics showed that, given the millions of dollars in denied claims at the first appellate level,
projecting out a greater than 75% overturn rate could yield a potentially significant negative cost
impact to the Medicare program and disclose an extraordinary level of agency inefficiency.
Graham (2014), who is affiliated with the Medical Group Management Association,
estimated that the average cost to rework a denied medical claim was $25 for each claim. The
MGMA further indicated approximately 50%–60% of claim denials are never addressed for
either resubmission or review by the submitting medical providers (Graham, 2014). The stated
reasons for failing to readdress the denied claims were lack of time or lack of knowledge on the

50
part of the submitting party. Graham advocated a high clean claims ratio, which is consistent
with the golden metric for insurance company submitted claims reviews. A clean claim is a claim
that was never rejected, did not have a preventable denial, was not filed more than once, and had
no errors. To illustrate the potential impact of a single unclean claim submission, a single claim
costs $25 to rework, and a medical practice processes 100 claims each month that require being
reworked. Subsequently, each month of reworked claims would cost $2,500 a month to process.
In a year, that monthly rework cost of unclean claims could conceivably cost the medical
practice an estimated $30,000. More concerningly, the adverse impact to a significant number of
Medicare patients who were denied claim payments for medically necessary treatments and
supported medical providers can be considered a national crisis.
The Participants
This chapter provides brief descriptions of each of the eight participants to enable the
reader to understand the varying perspectives of each participant as they relate to the three
research questions and the 12 interview questions posed to each individual participant (detailed
in the Appendix). Bogdan and Biklen (2011) posited that quoting subjects and presenting short
sections from the collected data help convince the reader and bring the reader closer to the
people who participated in the study. The average experience level for the study participants was
25.25 years. In addition, the participants were currently employed within various medical-related
clinical, academic, and administrative sectors within the medical industry and academia, which
permitted a diverse number of perspectives in response to the research questions.
Participant 1 is a man who has worked within the emergency room environment for over
30 years and has extensive experience with hospital medical coding-related billing charges.
Participant 2 is a chief medical officer with a major health care provider and has worked in the

51
medical field for over 27 years. He has experience in performing medical claim denial rate
reviews. Participant 3 is a sleep center biomedical engineer and is familiar with medical billing
accreditation standards. Participant 4 is a man with 20 years of experience teaching medical
education at the graduate level within the community college sector and at a university.
Participant 5 is a woman who is a director of an oncology department at a university and is
familiar with the claims appellate process. Participant 6 is a learning director at a medical
provider health care system. She considered it a “thorn in their side” as an organization to
constantly have to evaluate disparities between their organization’s submitted claims to Medicare
for patient medical treatment reimbursements and claim denial actions. Participant 7 has worked
as a medical practitioner and board-certified surgeon for over 30 years. He stated that the current
Medicare claim reimbursement care model adversely impacts the quality of care for Medicare
beneficiaries and patients. Participant 8 has been a vice president of hospital operations for the
past 13 years. She also has been employed as a medical group administrator, where she has
experience in Medicare claims payment actions and medical documentation compliance
programs.
As referenced in Chapter Three, the participating interviewees were convenience sampled
(Merriam & Tisdell, 2016) and purposefully network sampled by the researcher to permit a
consideration of the time, money, location, availability of the respondents, as well as permitting
potential sample size growth as more interviewees were contacted throughout the interview
process (Patton, 2002). Thirty-three prospective participants working for a MAC in the Medicare
claims sector were individually contacted through the LinkedIn professional network and
university online electronic forums. Only one respondent replied and stated she was not
interested in participating in the study. A secondary approach to identify study participants was

52
implemented by purposefully contacting networked known health care industry executives and
leaders within higher academia. The sample size consisted of eight men and women who were
recognized health care industry executives, medical physicians and surgeons, and higher
academics with executive health care experience.
The Qualitative Analysis
The data were collected using semistructured interviews via telephone call or Zoom
videoconference. Interviews were individually transcribed and subsequently uploaded onto the
ATLAS.ti 4.2 qualitative analysis software to identify emergent topic area data points. Eightyfive separate data codes containing 96 quotations were uniquely identified subsequent to
conducting both a combined and individual analysis of the eight transcribed participant interview
records in the ATLAS.ti 4.2 software. To efficiently align the 85 identified analysis codes into a
manageable format, the identified incidences of similar code occurrences were reduced to only
those codes that had similar theme occurrences within each code that equaled or exceeded five
occurrences (quotations). The codes with five or more occurrences are shown in Table 6.

53
Table 6
Filtered Code Analysis in Order of Most Occurrences
Filtered code group # of occurrences
Workplace effectiveness/factors/professionalism 22
Workplace challenges 19
Professional development 18
Efficiency 14
Interpersonal skills/skills 12
Motivation 10
Performance 8
System concerns 8
Belief 6
Expertise 6
Teamwork 6
Confidence 5
Management 5
Quality improvement 5
Research perspective 5
Resilience 5
The interview questions reflected in the Appendix were used to solicit comprehensive
and unfiltered responses from each of the voluntary study participants. The study incorporated
the guidelines and processes for qualitative data analysis discussed by Creswell and Miller
(2000). As previously discussed in Chapter Three, the ATLAS.ti 4.2 computer-assisted
qualitative data analysis software was used during this study to upload transcribed interviews and
notes contemporaneously taken during interviews. Gibbs (2018) explained that computerassisted qualitative data analysis is a popular form of qualitative analysis using transcription

54
from interviews. The large number of codes was evaluated and reduced to 16. The reduction to
16 coded themes was based upon an analysis of those similar codes that contained five or more
separate recorded occurrences of similar codes or identified interviewee quotations within the
eight uploaded transcribed interview records. This permitted a focused evaluation of similar
frequently occurring interviewee perspectives relating to the research questions. The ATLAS.ti
4.2 software also produced analytical results that transitioned all of the reduced thematic codes.
The themes and corresponding transcribed participant quotations, organized by themes or
hunches, as referenced by Gibbs (2018), are presented and discussed in relation to the study
research questions. What follows is a review of participant quotations corresponding to the
identified themes.
Results for Research Question 1
What are the beliefs of medical care providers in Medicare’s ability to render accurate
claim approval decisions? The evaluation of the selected coded themes and a review of the
corresponding participant quotations contained within their transcribed interviews uploaded to
the ATLAS.ti 4.2 software reflected an evenly divided belief in Medicare’s ability to render
accurate claim approval decisions. Participant 5 shared that her confidence is based on the
knowledge that improved electronic safeguards are now in place with the claim review process.
Participant 3 agreed with Participant 5 in the belief that Medicare is able to render accurate claim
approval decisions. In the opinion of Participant 2, CMS is approximately 80% reliable in
accurate claim approval decisions.
To the contrary, Participant 7 had no confidence at all in the Medicare claim review
process. In Participant 7’s opinion, Medicare is focused on administrative requirements versus
patient medical care. Participant 8 shared she was cynical of the Medicare claim review process

55
and that the claim denials appeared to be a strategy by Medicare to increase cost savings. She
also opined that she did not have confidence in the Medicare claim review process, as it causes
physicians to go out of business or become unable to remain in a medical practice.
Results for Research Question 2
What is the perception, based on lived experiences of health care professionals, of the
ability of Medicare to meet its mission statement of providing health care to Medicare
beneficiaries? The participants in this study characterized Medicare’s ability to meet its mission
statement of providing health care to Medicare beneficiaries as divergent. Participant 3 provided
an example of this divergence. Participant 3 posited that a health care organization may align its
rules with a medical specialty organization’s identification of specific comorbidities and
symptoms supporting a claim, such as that of the American Academy of Sleep Medicine, yet
Medicare rules for claims payment may be contrary to that specialty organization’s support of
the claim payment requirements. Participant 3 further discussed a scenario where a Medicare
beneficiary might have received a medically necessary DME apparatus for a sleep apnea
diagnosis. In this case, the beneficiary’s claim was under protracted review by Medicare, and as
a result, the DME medical provider retrieved the equipment from the beneficiary due to
nonpayment of the claim by Medicare. Participant 3 noted his organization is motivated to “go
above and beyond” to reduce process errors in supporting medical necessity determinations and
improve overall performance. Participant 8 stated “an entire team” is necessary to understand
how a claim is reimbursed by Medicare. This similar belief was held by Participant 2, who stated
he had insufficient time to work with Medicare personnel to adequately review patient charts and
perform “deep dives” into treatment and coding data required by Medicare claims in
documenting diagnostic data.

56
According to Participant 8, a physician’s productivity is predicated upon their ability to
exceed a certain volume of outcomes (based on number of patients) and relative value units. This
participant also stated that the previous administration of electronic patient health records was
being “woefully” managed at her facility. Participant 7 posited that Medicare’s emphasis on
administration “causes an exponentially increased incidence of patient care transitioning from
acute to chronic conditions.” The aggregate of participant sentiments illustrates a disparity in
confidence of clinical and administrative medical professionals to meet Medicare claim medical
necessity payment submission requirements. Still, these professionals are motivated to work
within their respective organizations and implement processes to improve overall efficiencies
and reduce administrative claim-related errors.
Results for Research Question 3
What do health care executives and leaders believe is necessary for Medicare to meet
organizational policies and strategies requiring them to align with the CMS mission statement to
support beneficiaries? Participant 3 stated that from an institutional perspective, his organization
conducts an internal review process for the submitted claim support data with the attending
physician in 1 day and allocates up to 3 days for associated clinical reviews. The entire process is
established to maximize efficiencies and minimize claim-related errors. He expressed that as
organizational profit margins and payment effectiveness are “shrinking,” medical-related billing
must be timely and preclude any departmental “backups.” Participant 6 described her
organizational goals as being focused on the “patient impact experience” with related medical
billing components in support of cost of care data results. Participant 2 stated that he reviews
returned Medicare invoices for payment and tracks the denial rates by Medicare for his
organization in an ongoing effort to reverse those particular trends for Medicare denied claims.

57
Participant 7 characterized his approach to providing satisfactory medical care delivery and
associated medical care follow-up reviews to his patients as “humanistic.” He also posited that
the time spent addressing administrative requirements established by Medicare for the
reimbursement of patient treatments detracts time from medical practitioners in the delivery of
quality of care.
Summary of Findings
The study highlighted 16 significant themes and multiple corresponding participant
quotations to elucidate a collective health care industry effort. The aim was to obtain and
evaluate the collective anecdotal inputs relating to issues associated with Medicare claims
processing from the lived experiences of health care executives. The effort also was to address
perceived disparities between health care organization medically necessary health care
treatments and Medicare submission of claims’ cumbersome and distracting administrative rules.
Merriam and Tisdell (2016) stated the goal of data analysis is to find answers to the research
questions, with answers referenced as categories, themes, or findings. Merriam and Tisdell also
described a unit of data being as small as a word a participant uses to describe a feeling or
phenomenon. Lincoln and Guba (1985) stated a unit should be heuristic, meaning the unit should
reveal information relevant to the study and stimulate the reader to think beyond the particular
bit of information. Additionally, the unit should comprise the smallest piece of information about
a topic that can stand by itself and be interpretable in the absence of any additional information.
The Medicare claim submissions by health care providers and institutions may be
adversely impacted by the large denial of claims. Whereas only a relatively small percentage of
the denied claims are appealed to higher Medicare appellate-level reviewers, a commensurate
large number of those denied claims are overturned as being satisfactory and supported claims. If

58
Medicare claimants are fortunate enough to have their claims reviewed at a possible significant
cost to the claimant, there is a strong likelihood the denied claims will be overturned at the ALJ
level of appellate review. The participants’ organizations attempt to compensate for the
possibility of a denied claim through internal process program improvements.
The participants recognized the encumbrance of Medicare claim submission rules and
policies. They worked diligently, from an organizational process improvement perspective, to
enhance the effectiveness and efficiency of their institutions to maximize opportunities for an
overall reduction of errors and delays in Medicare claim submission and payment processes.
Participant 1 stated, “The facility has to find a way to provide medical assistance to
beneficiaries.” He asserted that his institution addresses incidences of patient agitation and
navigating the Medicare claim appellate process in cases of Medicare claim nonpayment. The
interesting aspect of findings within this study is one remaining question, whether a clear
inefficiency exists within the Medicare claim submission review process at Medicare to render
satisfactory claim approvals for Medicare beneficiaries. A second questions remains asking that
if only 1% of all denied Medicare claim beneficiaries and health care providers appeal their
claim denials and over 70% are overturned at the ALJ level of appellate review, what beneficial
health care treatment is the beneficiary unable to receive due to Medicare nonpayment for the
other 99% of claims being denied by Medicare?

59
Chapter Five: Discussion
This chapter offers recommendations and practical advice to policymakers, health care
organizational leaders, clinicians, administrators, and other stakeholders on navigating,
understanding, and implementing processes for Medicare medical facilities and individual
medical providers to optimize the submission of clean claims for medically necessary
reimbursable medical treatments. The purpose of the study was to obtain and evaluate the
collective anecdotal inputs relating to issues associated with Medicare claims processing from
the lived experiences of health care executives. Results were gained through interviews with
eight health care executives with experience in Medicare claims processing.
Recommendations
Recommendation 1: Become Thoroughly Familiar With Medicare Claim Submission
Processing Rules and Policies
The study and interviews denote a sense of inadequacy within the overall medical
provider community and unfamiliarity with Medicare rules and policies pertaining to Medicare
claim submissions for payment of medical treatments. Specifically, Medicare policies, medical
and provider organizational clinical guidelines, local coverage and national coverage
determinations, and medical insurance carrier clinical directives associated with the submission
of clean claims are complex, are ambiguous, and may conflict with medical provider treatment
standards. The significant time and claim denial costs borne by Medicare claim-submitting
organizations certainly justifies a pronounced need to ensure satisfactory training of department
claim reviewers, evaluators, and others who submit claims for reimbursement to the Medicare
program.

60
The training would include general and specific clinical Medicare references to medically
necessary treatments, which support reimbursable treatment actions under Medicare policies that
are updated and align with provider claim submission internal policies and claim processing
procedures. This recommendation presumes medical treatment facilities and providers wish to
reduce denied submitted Medicare claims, improving claims processing times and
reimbursement for medically necessary treatments.
Recommendation 2: Determine Whether the Denial Was Based Upon a Clinical or
Administrative Reason
The research literature has indicated that the majority of Medicare claim denials are
attributable to administrative errors on the part of the claim-submitting provider or organization
(Graham, 2014; OIG, 2019). This may contribute to the significant overturn rate of denied claims
by the ALJs. Presumptively, if ALJs are overturning medical necessity reconsiderations by
lower-level Medicare claim reviewers and qualified independent contractor claim reviewers, they
may be attributable to either incorrect interpretations of claim-supported submissions or simply
administrative oversights by medical providers on the claim submission to Medicare.
Clinically based denials may necessitate a process review within health care
organizations to ensure medical procedures align with Medicare policies when Medicare
reimbursement is sought by the organization providing medical treatments to Medicare
beneficiaries. In addition, the medical treatments provided to Medicare beneficiaries must be
aligned to appropriate and correct medical billing condition codes found in the International
Classification of Diseases 10th edition, Current Procedural Terminology codebook, and the
Healthcare Common Procedure Coding System for medical commodities and injections.

61
Administrative claim submission anomalies can be easily identified, corrected, revised, and
resubmitted for reimbursement to Medicare within a Medicare policy-designated time frame.
Recommendation 3: Ascertain Whether There Is a Pattern of Similar Claim Denials Within
the Organization
The qualitative information and literature review in this study identified the majority of
denial actions by Medicare claim reviewers as being attributable to administrative anomalies.
This publicly available information can be utilized by organization utilization management
auditors or provider administrative clinicians to conduct a comparative analysis comparing the
Medicare data with the organization’s denial rate information to establish and identify patterns of
coding inefficiency or erroneous claim preparations by the organization claim submission
personnel.
One study participant posited a delineation of operational effectiveness between the
clinical and administrative staff: The clinical staff were relatively unfamiliar with the medical
procedural documentation requirements and had insufficient time to adequately complete
medical documentation to fulfill accurate claim payment requirements, while administrative
claim preparation personnel within the organization were attempting to interpret medical
practitioners’ notes and ensure compliance with Medicare medically necessary reimbursement
standards.
Recommendation 4: Institute Enhanced, Effective Internal Claim Preparation Protocols
Prior to Claim Submissions
As previously stated in the study, an increase in the effectiveness and efficiency of
preparing Medicare claims for medical treatment reimbursement results in an overall cost benefit
to the organization and effective reallocation of employee time. Each of the study participants

62
emphasized the difficulties encountered by their organizations in requiring a team of personnel to
satisfactorily prepare and submit Medicare claims for reimbursement. The participants and their
organizational administrative support staff endeavored to allocate the necessary internal
processes enabling them to minimize Medicare claim denial rates. One participant commented
that his goal was “to remain off the organization’s radar screen,” intimating that a high denial
rate of submitted Medicare claims was not a desirable condition within his organization.
Recommendation 5: Implement Organizational Policies That Evaluate the Cost Benefit of
Appellate Actions
The study and research literature elucidate a definitive need for organizations and
medical provider clinics to conduct internal reviews of their Medicare claims preparation and
submission processes. Claims that reflect similar medical procedures performed on Medicare
beneficiaries with similar billing and presented condition codes that are repetitively denied for
reimbursement by Medicare should be evaluated by cost benefit, frequency of denial actions, and
personnel time allocations in preparing supporting documentation for claim redeterminations,
reconsiderations, and possible ALJ reviews. In addition, the reported 3- to 5-year backlog of
requested ALJ third-level Medicare appellate reviews may preclude a practical cost benefit to
spend the time and financial resources to appeal a Medicare denied claim. Other factors may be
considered in this decision to appeal a denied claim, such as medical necessity compliance for
prescribed medical patient treatments to Medicare policy guidelines and rules.
Recommendation 6: Ensure Supported Appellate Actions Within Organizations Are Timely
and Thorough
Each level of Medicare appellate action requires a strict adherence to a request for appeal
of Medicare-denied claims within an established timeframe, normally 90–120 days. A medical

63
care provider or facility must track the date of a Medicare notice of overpayment or claim denial
and project the number of days remaining for the particular level of proposed appellate action.
Although labor intensive, the organization should conduct a thorough and comprehensive
internal review of the reason for the denied claim by Medicare. A patient’s unique subjective,
objective, assessment and plan documentation or patient clinical records should be compared
with Medicare medical necessity coverage determinations published by each MAC for
compliance and subsequent reimbursement. The results of the comparison will enable health care
leaders and administrators to render an informed decision on whether not to take any action,
resubmit a clean claim, or appeal the denied claim decision by Medicare.
Future researchers may develop increased insights and understand why there are denied
claim appellate backlogs. This research may influence evidence-based legislation and may help
persuade policymakers, health care executive leaders, medical practitioners, health-care-related
organizations, and medical billing personnel to review their internal Medicare claim preparation
and submission processes and policies. The research also may provide adequate guidance
enabling personnel to make informed decisions regarding engaging in a Medicare appellate
review of their denied claims with the knowledge that, statistically, they have a high probability
of prevailing in an administrative review of their matter.
Recommendation 7: A Need for a Government Accountability Office Audit Into Medicare
Appellate Backlogs
A substantive audit has not been conducted by the U.S. Government Accountability
Office into the effectiveness or efficiency of OMHA to satisfactorily address the backlog of
pending Level III Medicare appellate actions. Although CMS had a congressional mandate to
significantly reduce the appellate backlog, the effectiveness and methods utilized by OMHA in

64
meeting the congressional mandate have not been audited by the U.S. Government
Accountability Office. Any significant reductions in the backlog should be audited for validity of
actions in the claim administrative review process and causative actions attributing to any such
backlog reduction.
The Significance of Economic Evaluations
Levin et al. (2018) posited two significant outcomes in attempting to ascertain whether
interventions or opportunity costs are useful in attaining a particular goal or sets of goals. The
two desirable outcomes include a common goal to attain maximal program effectiveness for a
given budget or, conversely, to attain a given level of effectiveness at a minimal cost. Levin et al.
further indicated that the latter goal is unlikely to be accomplished if higher effectiveness and
lower costs are pursued as independent goals.
Levin et al. (2018) also posited that even though the economy and cost savings of larger
organizations may have an increased level of cost efficiency due to lower operating discounted
costs per item (e.g., claim reviews), such organizations may experience a reduced cost benefit by
marginalizing the number of claims ultimately approved for payment of beneficiary claims. For
example, the denial of claims by Medicare claim reviewers on a large scale may be perceived as
a potential significant cost benefit to the organization. In this particular case, the organization
does experience a cost savings, which is returned back into the U.S. Treasury. However, what
may be lacking is associated information on costs, effects, and benefits necessary to adequately
inform the decision as to a selection of potential alternative courses in determining benefit costs.
The Cost Analysis
The cost analysis involves the consideration of program interventions and resources that
have value (Levin et al., 2018). The ingredients method (Levin et al., 2018) provides an approach

65
to estimating the cost of varying interventions. This particular method is designed to assist an
economic evaluator by providing policy-relevant information relating to resource utilization. The
resource utilization information is then linked to effectiveness or economic benefits. The
ingredients method involves (a) identifying and specifying ingredients, (b) valuing and pricing
ingredients, and (c) calculating total cost and analyzing costs in such a way that the cost results
relate to the theory of change for the relevant intervention. Additionally, the calculations-derived
costs of the ingredients method may be used conjunctively with impacts to perform benefit cost
analysis.
When identifying and specifying the ingredients, analysts need to understand the problem
being addressed, the theory of change, and the components of the intervention design and
implementation (Levin et al., 2018). The ingredients need to be specified sufficiently enough to
enable a process that permits a reasonable assessment of price values. The common properties
associated with this particular effort include personnel, training, facilities, equipment and
materials, other program inputs, and required client inputs.
The Ingredients
The personnel ingredients include all human resources that would be required to
implement a program. The personnel ingredients category includes full-time employees, parttime employees, consultants, other program staff, any volunteers or interns, and each work
position occupant’s qualifications and time commitments. This category also includes the time
inputs that each person devotes to an intervention and labor time in-kind resources.
Training ingredients involving Medicare claim reviewers would focus on their
onboarding training, expanded professional training, expectations for training completion, and
reoccurring proficiency training. As an organization is potentially restructured to optimize

66
benefits and cost efficiencies, personnel may require retraining to enable them to operate within
a new department or position. In these cases, restructuring cost burdens may be distributed over a
year (Levin et al., 2018).
Facilities refer to physical spaces that may be required for an intervention. In this
category, it is prudent to evaluate facilities that may be jointly utilized by multiple programs or
departments as separate line-item costs. Many departments and organizations have standardized
department square footage data available as a part of the initial design development. These
requirements should be listed according to their dimensions and characteristics to permit the
identification of their value (Levin et al., 2018).
Equipment and materials include a variety of items such as books, manuals, computers,
software, furnishings, instructional equipment, peripheral devices, audiovisual equipment,
scientific apparatuses, printers, phones, internet access costs, printed materials, office machines,
paper, and other forms of office supplies (Levin et al., 2018). Again, the use of some of these
items such as computers may have multiyear value. Unique item descriptions that require larger
logistical components or faster processors should also be taken into account to accurately
evaluate item value.
The ingredients identified within the “other program inputs” category can yield a
behavioral outcome. Changing claim reviewer behavior can be induced by offering financial
incentives or motivational bonuses on successful attainment of program objectives (Barrow et
al., 2014). When other program inputs contribute to measured effects, they should be included in
the analysis (Levin, et al., 2018).
Another category of ingredients includes contributions that are required of medical
providers to submit the claims to Medicare for payment support and evaluation by Medicare

67
claim reviewers. The medical providers must submit clean claims devoid of any errors that
would preclude payment of the claim. In addition, the Medicare beneficiary relies on the accurate
claim submission to ensure appropriate medical coverage and reimbursement of provider care
and treatments. Sources of ingredient information are accessible from those responsible for
implementing interventions such as the claim reviewers (Levin et al., 2018). In this case, the
ingredients that are actually used, and not those proposed or perceived, should be considered as a
part of the interventions. Interviews are beneficial in evaluating the means by which ingredients
are used and contain important qualitative data (Levin et al., 2018). Specifically, semistructured
interviews permitted the researcher to explore unique staff responsibilities and insights enabling
program implementation processes within the organization. In this case, the interview is
considered a primary data source and should be conducted contemporaneously with the delivery
of the intervention (Levin et al., 2018). Surveys and observation techniques are also useful data
collection methods.
The Value of Ingredients
Market pricing is considered the most common method of assigning ingredients monetary
value (Levin et al., 2018), and the equilibrium price established by that market represents the
value of the good (Dorfman, 1967). The use of market prices is attractive due to their availability
and simplicity. Shadow pricing would be used in economic evaluations where an item has no
clear competitive market price (Boardman et al., 2011). Shadow pricing is based on an estimated
value.
In evaluating the prices of ingredients, there are two forms of differentiation to include:
site-specific versus expected or local versus national. Site-specific prices are the actual prices
that a program experiences in a specific geographic locality versus expected pricing, which may

68
incorporate pricing on a national basis. In some cases, national pricing may be adjusted for
geographic locations such as those denoted within the wage index files published by CMS
(2024b).
Levin et al. (2018) posited that the greater the detail the analyst has on the ingredients,
the more accurately these ingredients can be priced. Another significant consideration is the
forgone income on an investment that could have been realized if the resources had been used for
some other alternative. An annualization factor for determining annual costs of facilities and
equipment for different periods of depreciation and interest rates of facilities can be used to
estimate the undepreciated portion of annualized costs over the life of a facility.
Adjusting Costs for Inflation and Discounting Costs
In calculating costs for each ingredient (and considering higher costs for price inflation in
future years), prices are adjusted using indices such as the Consumer Price Index established for
each year. When costs are not adjusted for inflation, they are denoted as nominal or current costs
(Levin et al., 2018). The prices within the health care industry tend to rise faster than the general
rate of inflation.
Costs should also be adjusted for their time value, which is referred to as discounting
(Levin et al., 2018). The general understanding of discounting is that costs occurring in the future
are less of a burden than costs occurring in the present. Also, if the costs of multiyear projects
can be deferred until the latter part of the investment period, there is a reduced level of sacrifice,
or opportunity costs, realized by the entity. Analysts have used a variety of discount rates,
typically ranging between 0% and 11% (Barnett, 1996). In the health community, national
guidelines suggest a discount rate of 3% (Lipscomb et al., 1996; Neumann et al., 2016).

69
Induced costs should be considered regardless of whether the program is still in effect or
has been discontinued by the organization. Induced costs or postprogram costs, also referred to
as negative benefits in benefit-cost analysis, take into consideration the capture of full resource
implications of a program over a protracted period of time (Levin et al., 2018).
The Concept of a Benefit-Cost Analysis
The concept of willingness to pay is taken into account in Medicare’s willingness to
approve the provider-submitted claims enabling providers to be adequately reimbursed for
medically necessary treatments they provide to their authorized Medicare beneficiaries. The
conceptual framework used in the study incorporated Clark and Estes’s (2008) performance gap
analysis focusing on knowledge, motivational, and organizational influences affecting Medicare
claim reviewers and an educated assessment by health care industry leaders and executives in
evaluating MAC claim reviewers’ satisfactory ability to approve provided-submitted claims. The
conceptual framework incorporates the benefits received by every Medicare provider and
beneficiary directly or indirectly affected by the program (Levin et al., 2018). Levin et al. (2018)
emphasized the significance of measuring the costs to all groups of stakeholders in society,
ranging from program participants to the government. In benefit cost analysis, a three-step
process is used to apply the concept of willingness to pay by specifying benefits for use in the
analysis. First, the effects of the program are evaluated. Second, a shadow price based on
willingness to pay is calculated. Finally, to obtain the benefits, the size of the effect is multiplied
by the shadow price. Impacts are easier to evaluate with a shadow price if they readily
correspond to observed behaviors as opposed to knowledge, attitudes, or opinions (Duckworth &
Yeger, 2015). In the two classes of shadow pricing of behavior, or revealed preference approach
and contingent valuation approach, in the first there is a general assumption that individuals are

70
rational and well informed about the consequences of their decisions. The other approach
employs direct surveys of individuals to elicit their willingness to pay for outcomes (Levin et al.,
2018). In addition, Levin et al. posited that the appropriate value for the discount rate for benefits
(Burgess & Zerbe, 2013; Moore et al., 2013) is debatable, yet the rate should reflect the
opportunity cost of funds for the investment.
In the defensive expenditure method, the logic says that something can be valued by how
much society or an individual pays to avoid its opposite (Levin et al., 2018). A general approach
to monetizing these behaviors with commensurate consequences is to calculate the average
expenditure on such behaviors. The deficiencies associated with the defensive expenditure
method make it difficult to calculate all the resources used to avert the undesirable outcomes. In
the case of the ALG’s high overturn rates of previously denied Medicare claims, 70% of that
projected costs of the 99% of denied Medicare claims that are not appealed by either medical
providers or their beneficiaries may be considered a benefit to the organization and may be
repurposed for other necessary program needs within the organization.
The Benefit-Cost Ratio
The benefit-cost ratio is a simple adaptation from the net present value metric, which is
the discounted value of the benefits minus the discounted value of the costs. In the benefit-cost
ratio calculation, the net present value metric takes the difference between the present value
benefits and costs, and then the benefits are divided by the costs, as was shown in Equation 1. A
benefit-cost ratio greater than 1 means the benefits exceed the costs. Interventions with higher
benefit-cost ratios are preferred, and there is a strong presumption that interventions with ratios
less than 1 should be rejected by analysts (Levin et al., 2018). One of the advantages of the

71
benefit-cost ratio is it can be easily applied to show what, in investing, would be a return on
investment.
In a practical sense, Wheelan (2019) posited that the person (medical practitioner) who
knows most about the patient’s medical condition may have an economic incentive to deny
medical care. This unfortunate scenario may occur in cases where lifesaving procedures are
denied by insurance companies in order to save money. Wheelan continued by noting that under
any fee-for-service system, doctors charge a fee for each procedure they perform. The patients
pay for the additional testing and procedures, and the insurance companies or federal
government, via Medicare, pay for those additional costs. A patient’s insurance company and the
government may attempt to maximize profit by paying for as little care as possible.
Benefit Cost Calculations
The Office of Management and Budget (2021) Budget of the U.S. Government Fiscal
Year 2022 reflected an effort to reform Medicare payments to insurers and certain medical
providers to reduce overpayments and strengthen incentives to deliver value-based care to
Medicare beneficiaries, extend the life of the Medicare Trust Fund, lower beneficiary premiums,
and reduce overall federal costs.
As a part of the CMS (2022) Fiscal Year 2022 budget, Medicare Part A and B include
costs associated with ongoing operations, fee-for-service operations support, claims processing
investments, DME competitive bidding, and qualified independent contractor appeals for Fiscal
Years 2020 and 2021 with a projection for Fiscal Year 2022. In Fiscal Year 2022, the MACs
reviewed and dispositioned approximately 2.4 million Medicare first-level appeal
redeterminations (CMS, 2022). The Medicare appeals process affords beneficiaries, providers,
and suppliers an opportunity to dispute adverse determinations, including coverage and payment

72
decisions. The initial level of appeal commences with the MAC providing a redetermination of
the initial decision. The Large Appeals Settlement Initiative budgetary request pays for the
effectuation activities performed by the MACs to support CMS’s Large Appeals Support
Settlement Contractor, which is responsible for ensuring that all appeals settlements are executed
correctly. Appeals settlements result in the removal of settled appeals from OMHA’s pending
backlog. CMS estimates costs based on historical rates for the same function in previous years.
Section 521 of the Medicare, Medicaid and State Children’s Health Insurance Program
Benefits Improvement and Protection Act of 2000 (2000) requires CMS to contract with
qualified independent contractors to adjudicate second-level appeals resulting from an adverse
redetermination of a claim by a MAC during the first level of appeal. The law requires that
qualified independent contractors process Medicare Parts A and B claim appeals within 60
calendar days of receipt. The budgeted cost for this operational element includes annual
operational costs and activities that advance the department’s priority of continuing timely
adjudication of Medicare appeals at the second level of the appeals process.
The literature is vague on the Medicare funds that are appropriated or collected in annual
receipts for beneficiaries under the statutory provisions of this program. Interestingly, definitive
statutory provisions under Section 2718 of the Patient Protection and Affordable Care Act (201)
require an issuer of health care insurance for federal programs (e.g., Medicare, Medicaid, Federal
Employee Program) to provide an annual public report of how it used its premium revenue for
the prior calendar year. The purpose of this provision is to ensure that consumers receive value
for their premium by requiring that plans use enrollees’ premium dollars on medical care, quality
improvement activities, or paying rebates to policyholders. This process is commonly referenced
as the medical loss ratio (CMS, 2022).

73
Benefit-Cost Analysis
An analysis of the 3-year budgeted costs associated with CMS Medicare operations
evaluated the ingredients for personnel, facilities, supplies, training, and personnel travel costs.
The net present values for each of these categories were incorporated into a Microsoft Excel
spreadsheet, where they showed that the government discount rates were relatively low, at 0.75%
to 1.25% for the 3-year period covered in the analysis. These calculations showed that the
benefit-cost ratios increased significantly in the 1st year, with discounted rates being applied to
the budgeted costs and minor cost variances from year to year within each intervention option
period.
The benefit costs were notably higher in the first option period with a direct correlation to
the benefit-cost ratios for Fiscal Year 2020, at 8.66. In addition, the comparison of options
denoted that the benefits to the organization were higher when the realization factor was not
included in the calculations to identify organizational cost benefits. The realization factor takes
into consideration those costs associated with the time and average labor costs attributable to
claim reviewers having to review unclean claims during the redetermination and reconsideration
appellate reviews within the MACs. The realization factor further estimates that the costs
associated with unclean claim effort reviews may cost as much as one half of the calculated
benefits.
Recommendations for Future Research
The qualitative analysis and research literature developed as a part of this study do not
guarantee that a Medicare appeal action sought by an organization receiving a denied claim will
overturn the denial decision. The study did not address definitive performance gaps by Medicare
claim reviewers and the reasons for high denial rates being overturned by ALJs. In addition, the

74
study did not calculate a projection analysis of the potential impact to those providers and
Medicare beneficiaries within the 99% of submitted denied claims that are not appealed to the
Medicare appellate departments. With these considerations in mind, the following are
recommendations for future research:
1. Attempt to conduct a qualitative analysis of Medicare claim reviewers to evaluate any
identifiable information that could indicate knowledge, motivational, and
organizational influences that would account for a high claim denial overturn rate by
ALJs.
2. Explore identifiable process elements that would contribute to the 3- to 5-year
backlog of Medicare ALJ appellate reviews. Many medical providers rely on a
primary continual funding stream of Medicare reimbursements. Some are therefore
compelled to close clinics, a number operating within underserved communities, due
to delays in Medicare payments awaiting appellate decisions.
3. Conduct a linear regression analysis reviewing the 99% of denied claims,
extrapolated to a quantifiable figure that provides a projection, based upon a valid
statistical sampling method in order to determine the amount of denied claims-related
funds returned to the U.S. government.
4. Compare the individual medical providers’ and medical facilities’ impacts on the
operational and financial performance of their respective organizations due to
Medicare submitted claim denials.
5. Conduct a study to determine the impact of Medicare claim denials on individual
medical provider clinics and the corresponding number of clinics that either claim
bankruptcy or discontinue business operations.

75
6. Review and assess medical organizations through a study and analysis of medical
facilities and clinics that have recognized the laborious Medicare claim submission
process and have implemented successful programs and processes to reduce the
occurrence of submitted claim denials.
Conclusion
This dissertation involved the review of hundreds of sources addressing how the
Medicare denied submitted claims process adversely affects the health care industry. The
development of enhanced educational opportunities into Medicare claim submissions by health
care providers and organizations should enable them to become satisfactorily familiar with
Medicare claim submission policies and rules. The tenacity of many of these medical providers
is displayed in their recognition of the adversity they must overcome to provide clean Medicare
claims for reimbursement for medically necessary treatments provided to authorized Medicare
beneficiaries.
The study illustrates the propensity for medical patients to gravitate toward physicians
within their own demographic. Medical providers have discontinued their clinical treatments of
patients within underserved communities as their revenue streams are depleted in many cases
due to Medicare claim denial actions. Medicare needs to ensure it is fulfilling its mission
statement to help and benefit Medicare beneficiaries. Results of this study lead to asking the
question: If only 1% of Medicare beneficiaries/medical providers ever appeal their Medicare
denied claims, then what considerations are extended to the other remaining 99% of those
beneficiaries who do not appeal their denied claims? This matter is exacerbated by the
knowledge that over 70% of appealed denied Medicare claims that are reviewed at the ALJ level
of appellate review are overturned by the ALJs. This study provides insights that help to expand

76
knowledge promoting better health care outcomes for Medicare patients and an increase in the
number of continuing in-network and out-of-network medical providers able to treat Medicare
beneficiaries in a timely and medically necessary manner.

77
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Appendix: Interview Protocol
CMS’s mission is to serve Medicare and Medicaid beneficiaries. The CMS vision is to
become the most energized, efficient, customer-friendly agency in the government. CMS seeks
to strengthen and modernize the nation’s health care system, to provide access to high-quality
care and improved health at lower costs (CMS, n.d.).
The proposed respondents are healthcare industry executives and leaders with knowledge
of the CMS claim submission process. Three research questions guide this study and the
interview questions:
1. What are the beliefs of medical care providers in Medicare’s ability to render accurate
claim approval decisions?
2. What is the perception, based on lived experiences of health care professionals, of the
ability of Medicare to meet its mission statement of providing health care to Medicare
beneficiaries?
3. What do healthcare executives and leaders believe is necessary for Medicare to meet
organizational policies and strategies requiring them to align with the CMS mission
statement to support beneficiaries?
Introduction to the Interview
Today I am meeting with [Name of Interviewee, Position]_ as a part of a qualitative
effort of an approved study. The date [Date] and [Time] is . Good
morning/afternoon/evening and thank you for taking the time to meet with me. Let me introduce
myself. I am Michael Koslow and am conducting a study as a doctoral candidate at the
University of Southern California to gain insights into the knowledge, motivation, and
organizational guidance associated with the decision-making processes associated with Medicare

92
claim reviewer medical necessity assessments of provider-submitted claims for the treatment of
Medicare authorized beneficiaries. A series of questions will be asked to solicit your personal
opinions on the topic area. I will be recording the interview with your consent; as well as, taking
concurrent notes, which will enable me to review and capture the accuracy of the discussion. I
will be asking you for your verbal acknowledgement of your informed decision to willingly
participate in this interview. In addition, your identity will remain confidential within the
guidelines of the law and you will be identified with a number as a part of the study to maintain
your confidentiality when the study results are published in the future. In addition, no HIPAA
(Health Insurance Portability and Accountability Act) information relating to specific patients
and/or their specific associated medical data will be addressed as a part of this study. This study
includes various methods of using multiple investigative findings, sources of data, and data
collection methods to evaluate the findings. If you have any questions at any time during the
course of the interview, please feel free to ask those questions or for clarification. The interview
is expected to last approximately 45–60 minutes. Do you need any water or need to use the
restroom prior to starting the interview?
Research Question 1 Interview Questions and Potential Probes
1. Please elaborate if you as a medical administrator, academician, or clinician believe
you have sufficient training on local coverage determinations, national coverage
determinations, and medical coding methodologies? Potential probes are the
following: Is the training virtual, classroom, other and what is the frequency? Is your
training documented?

93
2. Please elaborate on your knowledge of where you may locate necessary job-related
policies, references, and manuals that align with the Medicare mission statement. Do
you regularly access and/or review those references in the performance of your job?
3. Please outline the procedures you use in your position to research Medicare claimrelated data to include techniques, methods, and steps. How is the progress
documented, if at all?
4. Can you please describe how you use your training to perform your job? Is the training
adequate in your opinion to evaluate claims for sufficiency and adequacy?
Research Question 2 Interview Questions and Potential Probes
5. Please elaborate on your confidence in your ability to evaluate the medical necessity of
a treatment in your position. Potential probes are the following: medical coding,
coverage determinations, agency policy considerations.
6. Would you describe your ability to comprehend a satisfactory “clean” claim. If so,
why? If not, why not?
7. Discuss your confidence in the accuracy of Medicare to render an accurate claim
approval decision. If applicable, to what do you attribute your lack of confidence?
8. Please elaborate if you believe you have adequate time to satisfactorily perform your
job as it relates to working with Medicare program personnel. What impediments, if
any, do you encounter in performing your job?
Research Question 3 Interview Questions and Potential Probes
9. Please describe the documented goals for your organization/department such as
timeliness and savings. Are those goals documented in a reoccurring evaluation
program?

94
10. Can you elaborate on what incentives are in place at your organization to meet or
exceed established position goals such as attaining established statistical goals? Do
you believe those incentives are fair? Why or why not?
11. Can you elaborate on your organization’s motivation for you to timely and accurately
submit organizational and/or division productivity reports? If disincentivized, why?
12. If you receive a performance evaluation, do you believe your performance
evaluations accurately reflect your work effort? Are there any disincentives or
distractors for you to optimize your productivity?
Conclusion to the Interview
Once again, thank you for your time, willingness, and candor to be interviewed and
recorded in support of this study effort. If you have any questions or additional input to the
interview within the next several days, please feel free to contact me at the number or email
being provided to you.

Abstract (if available)

Abstract This dissertation examined the perceived beliefs and impact of medical-provider-denied Medicare claims and the associated Medicare claims appellate process. Recognizing the high number of Medicare claims being denied, the relatively small number of those denied claims processed for appeal, the considerable backlog of administrative law judge (ALJ) appellate reviews, and the high number of appellate claim overturn rates, Medicare beneficiaries and medical providers are severely disadvantaged when seeking reimbursement for medically necessary treatments. The purpose of the study was to obtain and evaluate the collective anecdotal inputs relating to issues associated with Medicare claims processing from the lived experiences of health care executives. Administrative and clinical leaders within the medical community possessing executive health care industry experience addressed the factors that may contribute to the high number of Medicare claim denials with a commensurate Medicare appellate denial overturn rate by the ALJs. Using qualitative research methods, industry-recognized health care executive medical practitioners, administrators, and academic leaders were interviewed. These professionals did not have an overall high confidence in Medicare claim denial justifications. In addition, the professionals stated that Medicare claim denials may contribute to a reduced ability to deliver satisfactory and necessary medical care to Medicare beneficiaries. This dissertation contributes to the available research indicating that beneficiaries do have a proclivity to gravitate to medical practitioners within their own race or ethnicity and that incorrectly denied Medicare claims may adversely impact the Medicare-eligible elderly population.

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Asset Metadata

Creator Koslow, Michael Scott (author)

Core Title Medicare claim processing: an analysis of perceptions of lived experiences by health care executives and leaders regarding Medicare claim denials

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Degree Conferral Date 2024-08

Publication Date 08/14/2024

Defense Date 04/30/2024

Publisher Los Angeles, California (original), University of Southern California (original), University of Southern California. Libraries (digital)

Tag claim denials,gap performance research analysis,Medicare,Medicare administrative contractors,OAI-PMH Harvest,Office of Medicare Hearings and Appeals

Format theses (aat)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Lynch, Douglas (committee chair), Lenihan, David (committee member), Moore, Ekaterina (committee member), Rohrer, Brian A. (committee member)

Creator Email caccm2011@gmail.com,mkoslow@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC113998UKG

Unique identifier UC113998UKG

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Legacy Identifier etd-KoslowMich-13389

Document Type Dissertation

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Rights Koslow, Michael Scott

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