If Medicare pays refuses to pay for something that you believe is covered, or if it pays less than you believe is the correct amount, Medicare may be wrong.  You have the right to appeal.  Over 80 percent of Medicare claim reviews result in higher payments.

The material below applies to Original Medicare;  there are some differences from Medicare HMOs.

Some important things to know:

(1) You do not need a lawyer for the appeal.

(2)    A note from your doctor supporting your position is a valuable help.

(3)    File promptly, because there are deadlines (see below).

(4)    Keep copies of every document you submit.

(5)    Always send appeal documents by Certified Mail.  Specify Signed Return Receipt.

For every claim sent to Medicare, you should receive a Medicare Summary Notice (“MSN”) from  a private insurance company that processes Medicare claims in your area.  The MSN lists the service or equipment you received, the total amount billed, the amount Medicare paid and the amount you are expected to pay.  If the claim was refused, the MSN should include the reason.

If you have supplementary health insurance, you should also receive an Explanation of Benefits (“EOB”) from that company, listing the additional amount they have paid (if any).
 

Common Grounds for Claim Refusal

Medicare will refuse to pay when:

¨         They believe that the treatment or equipment was not medically necessary;

¨         They consider the treatment to be experimental;

¨         They believe that the treatment has been given to you more frequently than necessary;

¨         They do not find the information from your doctor sufficient to support the claim;

¨         They believe that the service or equipment is not covered by Medicare;

They believe that the treatment or equipment will not be of sufficient benefit to you.

The list on Page 10 does not include all possible reasons for refusal, but it shows the ones most frequently given.

 
If Medicare refuses payment or pays less than you believe they should, the first thing to do is to determine whether the claim was filed correctly.  One common error is use of the wrong Treatment Code.

If the form was correct (or if you doctor refuses to re-file the claim), you are entitled to appeal, but you must appeal within 120 days (that’s slightly less than 4 months) from the date on the Medicare Summary Notice.

How to Appeal

1. (a) Write a letter asking for a review.  Remember to include your Medicare number (that is usually your Social Security number with a suffix letter such as “A”) and the reason you believe that they should pay or that the amount should be higher.  Include a copy of the Medicare Summary Notice.  Keep the original.

Or

  (b) Simply write “Please review” at the bottom of a copy of the Medicare Summary Notice.  In this second case you do not have to give a reason, but you may include one if you choose.

2. Add any other documents that support your case.  If applicable, include a letter from your doctor explaining the medical reason for the treatment or equipment.  If applicable, include copies of relevant medical records (obtain them from your doctor).

3. Send the request and any supporting documents to the private carrier, whose name and address is in the “Customer Service Information” box in the upper right corner of the MSN.

The review will likely take six to eight weeks.  You will receive a notice of the decision.

When the Review Doesn’t Go Your way

If you are dissatisfied with the review and there is at least $100 in dispute, you can request a Fair Hearing.  You must make the request within six months of the time you receive notice of the review decision.  The notice will include instructions.  If you need help with the request, call 1800-MEDICARE (1-800-633-4227).

About the Fair Hearing

¨         Fair Hearings are informal.

¨         You have a right to review the hearing file prior to the hearing.

¨         You can have the hearing in person, by phone, or by mail.

¨         You may represent yourself or you may obtain the help  of a friend, a family member or an attorney.

If the Fair Hearing Appeal Doesn’t Go Your Way

Depending on the amount of money involved, you may have several additional levels of appeal.  All of them must be in writing:

1. Within 60 days of the Fair Hearing decision, you may file for a hearing before an Administrative Law Judge (ALJ) .  The process may take up to a year.

2. Within 60 days of the ALJ decision, if at least $500 is in dispute, you may file for a Departmental Appeals Board (DAB) hearing.

3. Within 60 days of the DAB decision, if at least $1,000 is in dispute, you may file an appeal to Federal Court.

There are somewhat different dispute sequences in the case of HMO’s, hospitals, nursing homes and home health care providers.

For More Information

For detailed information about any matters discussed in this article, consult the Social Security Administration (1-800-772-1213 / www.ssa.gov)  and the United States Department of Health and Human Services (1-877-696-6775 / www.hhs.gov) .

 

Much of the information in this article was obtained from the Medicare Rights Center, a non-profit, non-governmental, consumer service organization.  Their Web site is: www.medicarerights.org