Dealing with Medicare claim denials Nothing is more frustrating than having a claim denied. Here’s how to appeal — and what to expect. With millions of Medicare claims denied each year, theres a chance, while small, that it could happen to you. That can mean getting slapped with an unexpected bill when youre feeling under the weather already. The good news is that you have the right to appeal, and if you do, you have a decent shot at success. More than a quarter of denials appealed by individual beneficiaries are overturned once they reach a third level of appeal, according to a report by the Department of Health and Human Services. Still, getting there can be a long, tough haul, and people rarely win appeals at the first or second levels. That doesnt mean its not worth trying. People shouldnt be discouraged Beneficiaries should call their health care provider and get a letter stating why a service or drug is medically necessary and send it, along with any supporting documents, with the appeal. The timeline for appealing in Medicare Advantage plans can vary from plan to plan. Those in Traditional Medicare have 120 days to appeal the first time in what is called a redetermination. If the claim is denied again, they have 180 days to ask for a reconsideration. Seniors tend to have the most luck at the third level of appeal, when their case is heard by an Administrative Law Judge. Medicare beneficiaries have the right to ask for a video teleconference with the judge, which can sometimes benefit their case. Its an opportunity to tell the whole story. Patients are supposed to get a hearing and decision within 90 days - although a backlog means it can take more than two years. Seniors with Traditional Medicare can sometimes head off denial problems by looking out for an Advance Beneficiary Notice from a provider warning them that some services might not be covered. If you get one, contact your doctor before you get the service - barring an emergency - and make sure there isnt a simple fix, such as an incorrect billing code. Separately, people who think theyre getting discharged from a hospital, skilled nursing facility or home health care too soon can request a fast appeal. You should get a notice with appeal instructions that the covered care is ending, and you need to respond no later than noon of the day before your Medicare-covered services end. If you need help, The Center for Medicare Advocacy has self-help information at medicareadvocacy.org. You can also call the Medicare Rights help line at 800-333-4114. https://facebook/pages/Greenwich-Healthcare-News/222498034578730
Posted on: Mon, 11 Nov 2013 22:06:56 +0000
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