How to appeal when Medicare won't pay

CHICAGO Tue Nov 13, 2012 4:22pm EST

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CHICAGO (Reuters) - Medicare processed 906 billion outpatient insurance claims in 2010 - and refused to pay 10 percent of them. But if you're a senior on Medicare with a denied claim, your odds of turning that around are surprisingly good if you appeal.

The importance of pushing back when Medicare says no was highlighted recently by settlement of a class action lawsuit that will force Medicare to start covering skilled nursing and therapy services in institutional or home care settings - not only when patients have a demonstrated medical potential to improve, but also when they need care to maintain their current health status.

Long-term care services will be covered under Part A (hospitalization), while home care services will be covered under Part B (outpatient services). The settlement will transform the way that Medicare covers long-term care in the future - and claims filed after January 28, 2011 are eligible for review.

But there will be a murky transition period of a year or more as policies are rolled out, which means many seniors will need to push back when claims are denied. It's an easy process to appeal, and denials often are reversed, although you may need to go through multiple appeals to win.

In 2010, 40 percent of Part A appeals and 53 percent of Part B appeals were granted, according to the Centers for Medicare & Medicaid Services, which administers Medicare (CMS). Even in the case of big ticket durable medical equipment appeals, 44 percent of appeals were successful. More than half of appeals to Medicare Advantage and prescription drug plans are successful, too.

The Center for Medicare Advocacy (CMA), which filed the suit, is urging Medicare beneficiaries who think they qualify for coverage under the settlement's terms to start pushing for coverage right away by showing a copy of the settlement agreement to healthcare providers (here), and by submitting their claims to Medicare.

That process may entail appeals in some cases, says David Lipschutz, policy attorney at CMA. "People are very likely to continue to encounter this improvement standard issue, especially before CMS revises manuals and does any public education. "In some situations, they may need to file appeals."

Appeals make the most sense in cases where a service is denied and your doctor thinks you're entitled to it. Other strong cases involve denials where you suspect administrative error, such as incorrect coding done for a service. "If a denial was generated but the explanation of benefits doesn't look right to you, consider an appeal," says Douglas Goggin-Callahan, director of education at the Medicare Rights Center, a non-profit advocacy and consumer group.

Medicare consumer advocates offer these tips for filing an appeal:

* Just mail a letter

You don't need an attorney or consumer advocate. In the fee-for-service Medicare program, your paper trail starts with the summary notice of coverage you get in the mail. "It's as easy as circling what you think is erroneously denied, writing a sentence or two on why it should be covered, sign and date it, make a photocopy and send it back," says Goggin-Callahan. "That gets the ball rolling."

Initiating a claim with a Medicare Advantage or prescription drug insurer isn't much different - although drug appeals require accompanying written support from your physician. That can be done with a letter from the doctor, or by using a one-page form, which is available at the Medicare website.

* When to start

For Part B claims, you have 120 days to file an appeal after receiving written notice that Medicare won't cover a service you've received; for Medicare Advantage or Part D, you have 60 days. The appeal timelines are much shorter (usually 14 days) if you've been denied on a request for advance approval of services.

* Be persistent

If you're appeal is denied at the first level, keep going. You have the right to three additional levels of appeal, and the odds get better as you move along, according to Lipschutz.

* Getting assistance

For second-, third- and fourth-level appeals, you may want help. A good place to start is your State Health Insurance Assistance Program (SHIP), a network of non-profit Medicare counseling services that provides free counseling services. (find the SHIP program in your state: here) The Medicare Rights Center also offers free counseling by phone; (1-800-333-4114).

(The writer is a Reuters columnist. The opinions expressed are his own.)

(Follow us @ReutersMoney or here. Editing by Beth Pinsker Gladstone and Steve Orlofsky)

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