Appealing Medicare Decisions
It's Your Right
If Medicare refuses to pay for a health care service you received, you can appeal the decision. You have legal rights to get the care to which you are entitled, whether you have Original Medicare or a Medicare private health plan. Even if you sign an Advance Beneficiary Notice (ABN) that stated that you agree to pay for care if Medicare will not, you can still appeal. There is no punishment for challenging a Medicare decision. Most people who appeal a Medicare denial of a service are successful.
When you appeal a Medicare decision, remember to have your doctor help. You will need to read everything carefully and meet all deadlines. Your insurance provider will be able to give you more information. Keep photocopies and records of all communication, with Medicare, whether written or oral, concerning your denial. Send your appeal via certified mail or delivery confirmation.
The first step is to find out if it is possible that there was a billing mistake. Medicare uses a set of service codes for processing medical claims. Each medical service has been assigned a specific code. Sometimes medical providers accidentally use the wrong codes when filling out Medicare paperwork, and this can result in Medicare denials. A denial sometimes can be resolved easily by asking your doctor to double-check that your claim was submitted with the correct codes. If the wrong code was used, ask your doctor to resubmit the claim.
If your doctor is sure the correct code was used, you will need your Medicare plan to make an official decision. You must receive a written denial from the plan before you can start your appeal. Included in the denial notice will be information you need to start the appeals process. You have 60 days from the date on the denial notice to file an appeal with the plan. In most cases, you will need to send a letter to the plan explaining why you needed the service. You also should include a supporting statement from your doctor explaining why this service was medically necessary.
Once you appeal, the plan must make a decision within 30 days. If you do not hear back, call the plan. If the plan fails to respond within 60 days, it works just like a denial. If the plan does not make a decision in your favor, they must automatically forward your appeal to the Independent Review Entity (IRE). The IRE is an independent group of doctors and other professionals that contract with Medicare to ensure that you receive quality care. The IRE has 60 days to respond.
If the IRE upholds the plan's denial, there are additional higher levels of appeal to which you can take your case. The next level is an Administrative Law Judge (ALJ), followed by the Medicare Appeals Council (MAC) and then Federal Court.
In most cases, you do not need a lawyer to begin the appeals process, but if you are appealing at the ALJ level or higher, you may want to find an advocate or lawyer to help you.
Remember, you cannot appeal to Medicare to cover services that are never covered. For example, you can never ask Medicare to cover more than 100 days in a skilled nursing facility. If your Medicare Part D plan denies coverage for a prescription drug, you must use the Medicare private drug plan "exceptions" process to ask your health plan to cover a drug you need.
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Research & Resources
2010 Cost of Care Survey
According to the Genworth Financial 2010 Cost of Care Survey, a private room in an Ohio nursing home costs an average of $74,825 annually. The survey reports the costs for all types of long-term care, including home- and community-based care and residential care, by region, state, and in many cases, metropolitan area, nationwide. Overall, the survey found that the cost of care among facility-based providers has steadily increased, while "non-skilled care"-related home care costs have remained relatively flat.