The importance of pushing back when Medicare says no was highlighted recently by settlement of a class action lawsuit that will force Medicare to start covering skilled nursing and therapy services in institutional or home care settings - not only when patients have a demonstrated medical potential to improve, but also when they need care to maintain their current health status.
A doctor’s note can sometimes be a golden ticket – the proof you need to obtain the care for your health needs. But what happens when those needs are denied by Medicare? Roughly 10 percent of all Medicare claims are denied, which can be defeating for those who are in need of care. But don’t fret; you have the right to fight for your coverage.
Reuters recently published an article explaining “How to appeal when Medicare won't pay.” It is not an uncomplicated process, but if Medicare refuses to pay for services your doctor recommends it’s certainly worth your while to fight. The numbers are fairly enlightening:
In 2010, 40 percent of Part A appeals and 53 percent of Part B appeals were granted, according to the Centers for Medicare & Medicaid Services, which administers Medicare (CMS). Even in the case of big ticket durable medical equipment appeals, 44 percent of appeals were successful. More than half of appeals to Medicare Advantage and prescription drug plans are successful, too.
Medicare consumer advocates offer these tips for filing an appeal:
- Send a letter. Your paper trail starts with the summary notice of coverage you get in the mail. Take this notice, circle the erroneous denial, and write out why you think it should be covered. Make a copy, and mail one.
- Don’t waste time. You have 120 days to file an appeal for Medicare Part B claims, and only 60 days for Medicare Advantage or Part D. If you filed for pre-approval and were denied, you have only 14 days to initiate your appeal.
- Be persistent. You have a right to four levels of appeal, so don’t quit until you have exhausted all of your options.
- Get help. For appeals beyond the first level, you may want to seek help from an elder law attorney.
If you have questions about your Medicare claims and rights to appeal, seek appropriate counsel to assist in the process.
Reference: Reuters (November 13, 2012) “How to appeal when Medicare won't pay”