Disagree with a Medicare decision? – what can you do?

Despite its reputation, Medicare actually approves the majority of claims they process. According to the Centers for Medicare and Medicaid Services’ (CMS) financial report, CMS processes over 1 billion claims each year. In 2018, Medicare paid out about $731 billion in Medicare claims. 

However, now and again, Medicare rejects a claim for various reasons. If you disagree with a Medicare decision, you have the option to appeal the decision. You can appeal Medicare’s decision if Medicare denies you coverage for a requested service, drug, or item, or denies you reimbursement for a service, drug, or item you already received. You can also appeal Medicare’s decision if your request for a change in how much you pay for a service, drug, or item was denied. 

Medicare denials due to incorrect coding

One of the most common, if not the most common, reasons Medicare denies a claim for a service is incorrect coding. Doctors’ billing departments usually aren’t as well-versed in Medicare codes as they are in Marketplace billing codes, and Medicare has very particular coding requirements. 

For example, if a Medicare beneficiary goes to the doctor for a Welcome to Medicare visit but the doctor’s staff codes the bill as a regular doctor visit, Medicare won’t cover the claim at 100% as it should for Welcome to Medicare visits. Instead, Medicare will only cover 80% of the charge after assessing the Part B deductible. Therefore, before you file an appeal, be sure to investigate whether it was a simple coding error or not. Your doctor’s office should be able to help you with this process. 

If the coding was done correctly and you want to move forward with an appeal, here are the steps to take. 

Appeals process

The first thing on your appeal to-do list should be to round up all necessary documents that might help your case. Helpful documents may include doctor’s notes, the original itemized claim, the denial letter, your Medicare Summary Notice, and a detailed letter written by you explaining why you feel Medicare should reverse its decision. The more evidence you can show Medicare, the better your odds are for approval.

The next step will depend on the type of Medicare coverage you have. If you have Original Medicare with or without a Medigap plan, you will find an appeals form on the last page of your Medicare Summary Notice along with the mailing information for your Medicare claims office. Fill this form out and mail it to your claims office within 120 days from receiving your Medicare Summary Notice. You receive Medicare Summary Notices once a quarter, and they list how Medicare paid for services, drugs, and other items during the previous quarter. 

If you have a Medicare Advantage plan instead of Original Medicare, your appeals process is slightly different. The denial notice you receive for your plan carrier should have instructions on how to file an appeal. However, if you have any questions about the process, you should call your carrier directly. Your doctor should be able to help you with this process, as well. Unlike with Original Medicare, you only have 60 days to file an appeal through a Medicare Advantage plan. You can also appeal decisions made by your Medicare Part D plan carrier. 

What you should know after you file an appeal

While there are up to five levels of an appeal process, most people don’t need to move beyond the initial appeals stage. However, if your appeal is also denied, you will move up to level two and continue up to level five until a final decision has been made. 

Depending on the type of request and your type of coverage, the decision could take anywhere from 24 hours to 60 days. Try to be patient with the people processing your appeal, because in the end, a real person decides whether to approve your appeal or not.

Jeffrey Roberts

Emily Roberts: Emily, a former corporate lawyer, demystifies the world of law with clear explanations of legal principles, case analyses, and insights into the legal profession. Her blog is a valuable resource for law students, legal professionals, and anyone interested in law.