Savvy Senior: What To Do When Medicare Says No

Dear Savvy Senior,

What do you do when Medicare won’t pay for something that they’ve covered in the past?

Denied Dave

 

Dear Dave,
If you think Medicare should have paid for, or did not pay enough for, an item or service you received, you can appeal. And you’ll be happy to know that most people win, so it’s definitely worth your time. Here’s what you should know.

 

According to the Medicare Rights Center, 80 percent of Medicare Part A appeals and 92 percent of Part B appeals turn out in favor of the person appealing. The main reason for the high success rate is because many denials are a result of simple billing code errors made in the doctor’s office. But it’s also important to keep in mind that Medicare will only cover goods and services that are deemed “medically necessary.”

 

How to Appeal

 

If you have Original Medicare (Part A or Part B) start with your Medicare Summary Notice (MSN) that you received in the mail. This statement should list all of the services, supplies and equipment billed to Medicare for your medical treatment. This notice should also tell you why any specific claim was denied. Circle the items you’re disputing and the reason why. Then write “Please Review” on the bottom of your MSN, sign the back and provide your telephone number, and send it by certified mail or with delivery confirmation to the address on the form.

 

You’ll also want to include any information (like a letter of support) from the doctor or hospital about why the disputed service was medically necessary. And be sure to make photocopies and records of all communications, whether written or oral with Medicare concerning your denial, as a backup. You have 120 days from the date on the MSN to submit an appeal.

 

If you’re unhappy with the response you get back from Medicare, you can appeal to the next level which is a Qualified Independent Contractor, and if you are still unhappy, you can take it to an Administrative Law Judge. The final internal step is the Medicare Appeals Court, but, after that, denials still can be challenged in the Federal District Court.

 

Private Appeals

 

If you’re enrolled in Medicare Advantage (Medicare’s private plans, like an HMO or PPO) the appeals process is slightly different. One difference is that you have only 60 days from the date on the denial notice to file an appeal. Your health plan will give you the steps you need to take to appeal a denied claim, with the first step going directly to the plan for reconsideration. If it doesn’t decide in your favor, you can have it reviewed by an independent organization that works for Medicare, not for the plan.

 

Appealing Part D

 

If you’re in a Medicare (Part D) prescription drug plan, and you find out that your plan won’t pay for a drug you think should be covered, you have options here too. Your first step is for you or your doctor to call or write your drug plan and request a written explanation (called a “coverage determination”) of why they won’t cover your particular medicine. It’s best to do it in writing with your doctor’s statement explaining the medical necessity of your prescription. If you aren’t satisfied with their answer, you can appeal directly to the plan. If that fails, you can request a reconsideration from an independent review entity. Check your plan’s membership materials or contact your plan for details on how to appeal, or see www.medicare.gov/publications/pubs/pdf/11112.pdf.

 

 

Savvy Tips: For more information visit www.medicare.gov and click on “Medicare Appeals.” You can also get help through your State Health Insurance Assistance Program (SHIP) which provides free Medicare counseling to beneficiaries and their families and can help you understand the billing process and even file your appeal for you. To locate your local SHIP, go to www.shiptalk.org or call Medicare at (800) 633-4227. Some other great resources that can help if you have a question or complaint are your Quality Improvement Organization (to find your area office see www.medqic.org – click on “QIO Listings”), and the Medicare Rights Center which offers a consumer hotline at (800) 333-4114.

 

Send your senior questions to: Savvy Senior, P.O. Box 5443, Norman, OK 73070, or visit www.savvysenior.org. Jim Miller is a contributor to the NBC Today show and author of “The Savvy Senior” book.