Fighting Medicare Claim Denials

When an insurance company denies a claim in whole or in part, it is possible to appeal their decision. The same is true with Medicare claims...and in fact more than half of Medicare appeals are successful. If you, a family member, or a friend have had a Medicare claim denied, the following information can help you successfully appeal the decision:

Time Frame: If your Medicare claim is denied for less than the full amount, you can ask for a "redetermination" but you must do so within 120 days. Download the Medicare Redetermination Request form at http://www.cms.hhs.gov/cmsforms/downloads/cms20027.pdf, or call 800-633-4227 to receive a copy.

Common Denials: The denial you received will include an explanation, which you will need to contest in your appeal. Ask your doctor to write a letter addressing the reasons in the denial and include this letter with your appeals form.

Common denials include:
The treatment, prescription, or medical service is unlikely to cause your health condition to improve: Fight this by having your doctor write a letter explaining why the care is necessary. Medicare is required to look at your total condition, not just your chance for a full or partial recovery.

You are likely to require care for a very long time: Medicare coverage is not limited to treatments that work quickly, so ask your doctor to write a letter explaining that the treatment is making some positive difference or is expected to.

The prescription dosage level is greater than what is normally prescribed, or the drug prescribed is not normally prescribed for your health problem: Have your doctor write a letter explaining why the unusual drug or dosage is medically necessary. For instance, you may be allergic to the medicine normally prescribed.

You do not qualify for Medicare-covered home care because you are not homebound: Under Medicare rules, homebound does not mean that you are completely unable to leave your home or that you are confined to a bed. It does mean that you require assistance and that it takes considerable effort for you to leave your home. Ask your doctor to write a letter describing in detail how difficult it is for you to leave your home.

Be Persistent: If your first appeal is denied, you can file as many as four more appeals. And the more appeals you file, the greater your odds of success. While your first appeal is made to the same group that denied your initial claim, subsequent appeals are made to independent arbiters.

For more information, visit www.medicareadvocacy.org