Brenda Lyle – Florida Today
Q: Why was my Medicare claim denied?
A: Medicare is a federal health insurance program that provides essential healthcare benefits for millions of Americans aged 65 and older, as well as certain younger individuals with disabilities. But not every claim for services or treatments is paid. Let’s explore the most common reasons for Medicare denials — and your options.
Medicare Denial
Medicare denials refer to situations where a claim for healthcare services or treatments is rejected by Medicare. Happily, you can fight city hall. According to hhs.gov, 28.2% of all Medicare appeals in 2023 resulted in a favorable outcome for beneficiaries. The quarterly “Medicare Summary Notice” might be your first clue that an office visit or treatment has been rejected — but many people don’t read it! It will note why your claim was denied and is important during the appeals process. Denials occur for many reasons, including improper coding, incomplete documentation, medical necessity concerns or coverage limit issues. Some treatments require prior authorization by Medicare and will be denied if your physician did not request it.
Levels of Appeal
– Redetermination: The first step is to request a redetermination (review) of the claim. Conveniently, the form to request a redetermination is included with your Medicare Summary Notice.
– Reconsideration: If you are dissatisfied with the redetermination outcome, the next level is to request reconsideration by a Qualified Independent Contractor (QIC) not involved in the previous decision.
– Administrative Law Judge (ALJ) Hearing: If the reconsideration outcome is still unsatisfactory, a hearing can be requested.
– Medicare Appeals Council Review: If the ALJ decision is unfavorable, the next level involves requesting a review.
– Federal District Court: If the Medicare Appeals Council does not rule in your favor, the final option is to file a lawsuit in federal district court.
Timelines and Procedures:
Strict (and varying) timelines exist for each appeal level, so prompt action is crucial. Beneficiaries must complete the required forms and provide supporting documentation. Impassioned, emotional language is not helpful. Provide evidence about your claim and cite the Medicare coverage rule you believe applicable.
Help is Available
Free assistance is available from the State Health Insurance Assistance Program (SHIP) and Medicare Rights Center. In addition, Medicare.gov provides detailed information (and contact information) related to the appeals process. You may also tap your attorney or designated representative to help.
Not surprisingly, navigating the Medicare appeals process is complex. But it can be done. Diligence is key, as is understanding the reasons for denials, appeal levels, timelines and procedures. Oh –and start reading your Medicare Summary Notice!
One Senior Place is a marketplace for resources and provider of information, advice, care and on-site services for seniors and their families. Questions for this column are answered by professionals in nursing, social work, care management and in-home care. Send questions to AskOSP@OneSeniorPlace.com, call 321-751-6771 or visit One Senior Place, The Experts in Aging.
Brenda Lyle is a Certified Care Manager and Certified Dementia Practitioner with One Senior Place, Greater Orlando.
