10% of Medicare Beneficiaries Have Claims Denied: Here’s How to Appeal a Decision

10% of Medicare Beneficiaries Have Claims Denied: Here’s How to Appeal a Decision

Medicare provides essential health coverage for millions of Americans, but sometimes claims get denied. If you find yourself in this situation, it’s important to know that you have the right to appeal the decision.

The Reality of Medicare Claim Denials

A survey revealed that 69% of consumers whose claims were denied didn’t know they could appeal, and 85% of them didn’t file an appeal. Understanding how to navigate the appeals process can ensure you receive the coverage you deserve.

Steps to Appeal a Medicare Decision

1. Assess the Viability of Your Appeal

Before starting the appeals process, consider whether your appeal is justified. Jen Teague, director for health coverage and benefits at the National Council on Aging, suggests that an appeal is worth pursuing if you genuinely believe the service is medically necessary or if there’s a risk involved in not receiving the care.

2. Consult with Your Physician

Speak with the doctor who provided the service. If they agree that the service was necessary, ask them to write a letter to include in your appeal. This letter can significantly strengthen your case.

3. Understand Common Reasons for Denials

Sarah Murdoch, director of client services at the Medicare Rights Center, notes that common denial reasons include:

• Annual Service Limits: If you exceed the allowable frequency for a service within a year, ensure the service is correctly coded as medically necessary rather than routine.
• Prescription Drug Quantity: Discrepancies between prescribed quantities and what the plan covers.
• Hospital Stays: Distinctions between inpatient status and observation status, which can affect eligibility for subsequent rehabilitation coverage.

4. Immediate Review and Expedited Appeals

If you’re being discharged from the hospital too soon or if services from a home health agency, outpatient rehabilitation, or skilled nursing facility are denied, you can request an immediate review or expedited appeal. Contact your Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) for assistance.

How to File an Appeal

1. Gather Necessary Information:

1. • Your name, address, and Medicare number.
   • List of the items/services you are disputing.
   • Explanation of why these should be covered, ideally with a supporting letter from your doctor.
   • Name of your representative, if applicable.
   • Any additional supporting information.

1. Submit Your Appeal:

1. • Mail the appeal to Medicare at the address on your Medicare Summary Notice (MSN) within 120 days of receiving the MSN.
   • Keep copies of all documentation for your records.

1. Types of Appeals:

1. • Standard Reconsideration: Typically requires a written request.
   • Expedited Reconsideration: Can be requested verbally or in writing, especially if delay poses a serious health risk.

1. Response Times:

1. • Expedited Requests: Response within 72 hours.
   • Standard Requests: Response within 30 calendar days.
   • Payment Requests: Response within 60 calendar days.

If You’ve Already Purchased Prescription Drugs

If you’ve already purchased the drugs, file a standard appeal in writing. If seeking coverage for future prescriptions, request a coverage determination or an exception from your plan, which may require a supporting statement from your prescriber.

Appeal Levels

If the initial appeal is denied, you can escalate through five levels:

1. Initial Appeal: As described above.
2. Qualified Independent Contractor Review.
3. Office of Medicare Hearings and Appeals.
4. Medicare Appeals Council Review.
5. Federal District Court Review.

Each level provides instructions for further appeals if necessary.

Additional Support

For help with filing an appeal, contact your State Health Insurance Assistance Program (SHIP). You can also appoint a representative to file the appeal on your behalf, such as a friend, family member, attorney, or doctor.

Conclusion

Appealing a denied Medicare claim can be complex, but understanding your rights and following the correct steps can significantly improve your chances of a successful appeal. For any questions or assistance, reach out to the Medicare Rights Center at 800-333-4114 or consult with your local SHIP office.

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