Medicare Appeal Process

Medicare Denial

One of the biggest fears people have when they come to my office, for example, is backbreaking medical bills.  A major concern is: ‘Will Medicare cover . . . . ?   You can then imagine how clients react when Medicare does not cover a bill. 

Fortunately, I do not get many frantic phone calls from clients who are upset because Medicare denied a claim.  Medicare denials, however, do happen.  Most of the time, a Medicare denial is simple to handle.  At other times, there needs to be a formal Medicare appeal process.

First of all, what is a Medicare denial of coverage?  A denial is when Medicare, the Medicare Advantage plan, or the Medicare Part D prescription drug plan refuses to cover and pay for a particular procedure or medication. 

This denial may come in many forms.  The Medicare denial letter may come before the procedure.  The doctor’s office calls to get prior authorization, and the procedure is denied.  The denial may come after the procedure is performed, and Medicare denies payment.  The patient may be in the midst of the procedure, such as staying in a hospital, skilled nursing facility, or receiving home health care. Medicare refuses to cover additional time in the institution.

Understanding How Medicare Coverage Works

One time I had a client who had a serious shoulder problem.  The doctor recommended an MRI.  The Medicare Advantage plan denied the treatment.  They suggested a less expensive treatment to repair the situation–physical therapy. 

The client called me to complain.  After a few phone calls with the insurance company, they explained physical therapy was far less expensive, and it may achieve the same result without being so intrusive as surgery. 

The purpose of the MRI was a preliminary to surgery.  The client later said he had no intention of having surgery at his age.  He simply wanted to know what was wrong with his shoulder. 

Most situations can be easily resolved without going through the Medicare appeal process.

Medicare and the insurance companies will almost always take the least expensive and intrusive route when prescribing treatments.  A denial is not always a denial.

Medicare Summary Notice

Medicare sends a quarterly statement, the Medicare Summary Notice (MSN).  It lists all the procedures you have had in the past quarter, the cost, and the payment.  The MSN is not a bill. It is a notice that people with Original Medicare get in the mail every three months for their Medicare Part A and Part B-covered services.  The MSN shows all services and supplies billed to Medicare during a 3-month period, what Medicare paid, and the amount you owe.  It will also show denials.

Another client of mine was denied access to a Skilled Nursing Facility (SNF).  She had had a knee replacement.  Usually, patients go directly home after a knee replacement.  In her case, the rehabilitation was not going well.  Her home was a small apartment with pets.  She lived alone.  When Medicare denied the request, we had the doctor put she was a “fall risk” in the letter to Medicare, and he laid out the reasons.  The appeal was quickly granted. 

Many times it is not an issue of denial of coverage; it is poor communication.  In this instance, we did not even use the formal Medicare appeal process.  It was just a letter of clarification from the doctor.

Medicare Appeal Process

If you disagree with the Medicare coverage determination, you can appeal the decision.  An appeal is a formal way of asking Original Medicare (Part A & Part B), the Medicare Advantage Plan, or the Part D plan to review and change the coverage decision. 

A Medicare appeal is different than filing a grievance or complaint with Medicare.  Grievances deal with the quality of coverage, the listing of medications on formularies, or access to medical personnel and institutions. 

An appeal asks Medicare to pay for a procedure it denied.  For example, an appeal may ask Medicare to extend a patient’s stay in a skilled nursing facility beyond her situation’s customary period.  An appeal may ask Medicare to approve a more expensive procedure than is ordinary for the situation.

As a Medicare beneficiary, you have a right to file an appeal.  There are five levels to an appeal.  Medicare Advantage and Part D plans mirror the same process.  If you are dissatisfied with the decision at the last level, you may proceed to the next level.  The denial letter includes instructions on how to apply.

Medicare Redetermination Form For Appeal Process

Once you are aware of a Medicare denial of coverage with which you disagree, you need to act.  You have 120 days to respond. 

Download and complete the Redetermination Request Form.  The form goes to the Medicare contractor, or you can write your own letter.  Remember to include all the essential information.  You will receive a Medicare Redetermination Notice within 60 days after Medicare, or the contractor receives the letter.  If you disagree with that decision, you have 180 days to appeal to Level 2.

Medicare Reconsideration Request Form

A Qualified Independent Contractor (QIC) administers the 2^nd Level of appeal, not Medicare or the insurance company contracted with Medicare.  It is a third party that reviews the case.  The appeal process is the same as the previous.  There is a designated form—the Medicare Reconsideration Request Form.  The decision is rendered in 60 days or less.

Administrative Law Judge

If you disagree with the decision from the 2^nd Level, you may proceed to the 3^rd Level, which is the Administrative Law Judge Hearing.  You have 60 days to make this appeal. 

Of course, there is a specific form for this appeal, and it is sent to the Office of Medicare Hearings and Appeals (OMHA) Central Operations.  The address is on the form.  If you are not satisfied with this decision, you may appeal to the 4^th Level within the 60 days allotted.

Medicare Appeals Council

The 4^th Level in the Medicare appeal process is like the others.  The council has 90 days to respond.  If you still are not satisfied, you may take your appeal to a district court within 60 days.

Federal District Court Judicial Review

The 5^th and final Level is the Federal District Court Judicial Review.  Cases that make it this far usually significantly impact Medicare when won.  This is the “supreme court” of the Medicare world.

Medicare Appeal Process Help

Please, call when you have questions about appeals.  We can help steer you in the correct direction.  You can also call Medicare directly.  They are open 24/7.  They will mail or email you the required forms as can we. 

If your appeal is to an Advantage or Part D plan, you call them directly.  Their appeal process mirrors the Medicare appeal process and is usually less formal.  You can also call the local SHIP (State Health Insurance Assistance Program) office to assist you.

Expedited Review

Many times speed is essential in a decision.  The Medicare beneficiary may request an expedited review. 

For example, you are in a hospital.  The doctor thinks you need an additional three days because your body is not recovering from the treatment at the average speed.  It is three days beyond what Medicare allows.  Medicare will deny payment.  The hospital files the Medicare Redetermination Form requesting three extra days.  They also request an expedited review, which means Medicare will make a decision within 72 hours.  An expedited review for medications on a Part D plan is 24 hours. 

The Beneficiary and Family-Centered Care-Quality Improvement Organization (BFCC-QIO) is the department that will help with appeals.

Handling NO!