Woman helping senior mother appeal a Medicare denial

It’s not uncommon: you or your parents submit a claim to Medicare, and the claim is denied. Do you have any recourse?

The short answer is: “Yes!” But before we describe how to appeal Medicare’s decision, let’s briefly outline what Medicare is.

Medicare in a Nutshell

Created in 1965, Medicare is the federal health insurance program for people who are 65 or older. Some younger people with disabilities and end-stage renal disease are also eligible for Medicare. The different parts of Medicare are: 

  • Part A, or hospital insurance; 
  • Part B, or medical insurance; and
  • Part D, or prescription drug coverage. 

Most people don’t pay a monthly premium for Part A. Everyone pays a monthly premium for Part B. Part D has monthly premiums and extra costs.

Participants must enroll in either Original Medicare or Medicare Advantage. 

  • Original Medicare includes Parts A and B. You can add Part D if you wish. You pay for services as you receive them. There is a deductible, and you usually pay 20% of the cost of approved services. You can also pay for Medicare Supplement Insurance for extra coverage, known as a Medigap policy.
     
  • Medicare Advantage is a health plan from a private insurer that includes Parts A and B, often Part D, and may provide vision, hearing, and dental services. Medicare Advantage plans have out-of-pocket costs.

The North Carolina Medicare and Seniors’ Health Information Program is a resource on Medigap policies specific to North Carolina. Note that Medicare does not pay for long-term care. Carolina Family Estate Planning has many articles and videos on approaching long-term care planning for yourself and your loved ones.

Denied? You Are Not Alone

More than 63 million Americans were enrolled in Medicare in 2020. With that many enrollees, combined with millions of medical procedures, billing mistakes will undoubtedly be made. One of those mistakes might arrive in your mailbox.

First Steps

Look at the Medicare letter: is your claim rejected or denied?

If it is rejected, this means Medicare did not have enough information to process your claim. For example, a medical code may have been inputted incorrectly, or the treatment dates are missing. Have your medical provider review the information and resubmit the bill.

If your claim is denied, this means Medicare has issues with the information you provided. The letter will list the reason(s) for denial. The problem may be due to human or computer error, or it may be that Medicare thinks your claim violates its policies. Speak with your medical provider for clarification.

Filing an appeal: Original Medicare

There are five levels of appeal, or “redetermination,” as Medicare calls it.

  1. Redetermination by a medical administrative contractor. You must file an appeal within 120 days of receiving the Medicare letter. Once your appeal is received, the contractor should issue its decision within 60 calendar days.

  2. Reconsideration by a qualified independent contractor. You have 180 days to file your appeal to the redetermination. The contractor has 60 days to answer you upon receipt of your appeal.

  3. Hearing by an administrative law judge or review by an attorney adjudicator in the Office of Medicare Hearings and Appeals. You have 60 days to file your appeal for reconsideration. The amount in dispute must be at least $170. The office has 90 days to respond.

  4. Review by the Medicare Appeals Council. You have 60 days to appeal the hearing’s decision, and the Medicare Appeals Council must respond within 90 days.

  5. Judicial review in U.S. District Court. If you disagree with the Medicare Appeals Council’s decision, you have 60 days to file a lawsuit. The disputed amount must be at least $1,670.

In 2020, more than 390,000 appeals were filed for Part A claims, and 44% were settled favorably (4% partially favorable) to the claimant. More than 2 million appeals were submitted for Part B bills, and 52% were favorable (3% partially favorable) to the claimant. The process may be painstaking, but it pays to appeal.

Filing An Appeal: Medicare Advantage

Like the five levels outlined above, the Medicare Advantage process also has five levels of appeal. However, since health plans have the authority to approve or deny bills, the first step in disputing a decision is to file an appeal with your insurance provider.

If your health plan denies your appeal, it will automatically be sent to an independent review entity (step two). Steps 3-5 are identical to the Original Medicare appeal process.

Carolina Family Estate Planning: We’re Here to Help 

Medicare takes appeals seriously. So does Carolina Family Estate Planning. If you’re dealing with a Medicare denial in North Carolina, our elder care attorneys are experienced in filing and winning appeals. Call us today at 919-443-3035 or schedule a needs assessment call.  We’re here to help.

 

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The information in this blog post (“post”) is provided for general informational purposes only and may not reflect the current law in your jurisdiction. No information in this post should be construed as legal advice from the individual author or the law firm, nor is it intended to be a substitute for legal counsel on any subject matter. No reader of this post should act or refrain from acting based on any information included in or accessible through this post without seeking the appropriate legal or other professional advice on the particular facts and circumstances at issue from a lawyer licensed in the recipient’s state, country or other appropriate licensing jurisdiction.

 
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