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Appealing a Medicare Claim: Is It Worth Your Time?

medicare claim formMedicare is the primary insurance for many Americans over the age of 65, with nearly 50 million people enrolled last year. Although Medicare claims are often processed with few issues (especially given the high number of enrollees), there are times when Medicare denies a service that should be covered.

If you are experiencing problems receiving approval for some of your medical services to be covered by Medicare, you may not be aware that you can appeal the decision to deny payment. Although it may not be the simplest process, appealing can often lead to a favorable outcome.

Common Problems with a Submitted Claim

If you have submitted a claim to Medicare and it was denied, there are a couple of things you need to do before making an appeal. First and foremost, make sure all of the information submitted by the provider is correct. A small mistake such as transposing your Medicare number (which is also your Social Security number) or having the wrong birthdate can be enough to cause a claim to be rejected.

Additionally, make sure the billing was submitted to Medicare correctly. Office staff can make mistakes in coding a bill, which is how Medicare decides whether the service you received is a covered expense. If the coding is wrong, have it corrected and resubmit the claim. If that was the problem, Medicare will likely issue payment.

How To Begin The Appeals Process

If all of the information on the bill is correct and Medicare is still rejecting the claim, you may need to appeal the decision. You can look on the back of the rejection statement you receive from Medicare to find out what information you need to have available for the appeal, as well as the time frame in which you have to appeal.

Generally speaking, you have 120 days from the time you receive your quarterly Medicare summary to file an appeal. The initial process is uncomplicated—you simply circle the item for which payment was rejected, attach a letter from your doctor or other documentation that may help, and resubmit it. A reviewer will take a look at the information and make a decision, usually within 60 days.

At this point in the appeals process, if Medicare continues to deny the claim, you can request that a different claims adjustor review the charges in question. If the second adjustor also denies payment and the amount in question is less than $140, you have exhausted your appeals and are responsible for making the payment out of your pocket.

What If The Claim Is Still Denied?

However, if the amount of the claim is over $140, you still have options. You can request that a hearing be held, at which point you will be able to produce witnesses and any documentation that you think will help win the appeal. This hearing takes place in front of a judge who practices administrative law.

If the payment is still denied, you can take your appeal to an appeals council reviewer and even on to District Court if you are still not satisfied and if your claim amount if over $1,400. Once you reach that point, the decision is final, either way.

When Claim Review Can Be Expedited

There are certain circumstances where you can receive an expedited decision when you appeal a payment denial by Medicare. For example, if you have had a prescription drug claim denied, you can fast-track the appeal and receive the decision within 72 hours provided you can prove that your health is in danger if you do not have your prescription.

The rules are slightly different for Medicare Part D plans and Medicare Advantage plans, so you need to be sure you are submitting the appeal within the time frame allowed. Typically, the time frame for these plans is only 60 days.

Appealing is Definitely Worth Your Time!

Although you may have heard that appealing a Medicare denial is futile, you should know that at least 40 percent of all Medicare decisions are reversed. If you are looking at an appeal where the amount is only a few dollars, you may well decide to simply pay the bill yourself. However, if you are looking at a hundreds or even thousands of dollars, appealing the decision is definitely worth your time.

If you have questions about the process of appealing a decision made by Medicare, remember that the Personal Advisors at MediGap Advisors are experience, licensed insurance professionals who are well-versed in all aspects of Medicare.

Wiley Long

Wiley Long

Wiley Long is founder and president of Medigap Advisors, and is passionate about helping people navigate the confusing waters of Medicare. He is the author of The Medicare Playbook: Designing Your Successful Health Coverage Strategy, a clear and simple explanation so you can make the most of your Medicare coverage. For more information visit www.MediGapAdvisors.com.
Wiley Long

 

 
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