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Medicare News

Seniors Need To Be Tenacious In Appeals To Medicare

Helpful instructions for senior citizens on how to file an appeal - below news story

By Susan Jaffe, Kaiser Health News
This story was produced in collaboration with The Washington Post

Dec. 18, 2012 - Dan Driscoll used to be a smoker. During a regular doctor's visit, his primary-care physician suggested that Driscoll be tested to see if he was at risk for an abdominal aortic aneurysm, a life-threatening condition that can be linked to smoking. The doctor said Medicare would cover the procedure. So Driscoll, 68, who lives in Silver Spring, had the test done and was surprised when he got a bill from Medicare for $214.

 

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"I didn’t accept that," he said, because based on everything he had read from Medicare, he was sure this was a covered service. So Driscoll did something that seniors rarely do: He filed an appeal.

Of the 1.1 billion claims submitted to Medicare in 2010 for hospitalizations, nursing home care, doctor's visits, tests and physical therapy, 117 million were denied. Of those, only 2 percent were appealed.

Few seniors have the patience, tenacity or health to question a coverage denial, say advocates and counselors in the Washington area. And those who do appeal but lose on the first try tend to give up too soon, they say.

"People lose, and then they lose heart, or they are too sick, too tired or too old, and they give up," said Margaret Murphy, associate director of the Center for Medicare Advocacy, which has offices in Washington and Connecticut. "Or their kids are handling the appeal and they are too overwhelmed caring for Mom or Dad."

Medicare officials say appeals are rare, though they would not provide statistics on how many appeals came from beneficiaries rather than from health-care providers, such as hospitals, doctors and nursing homes. The inspector general's office in the Department of Health and Human Services reported last month, however, that 85 percent of appeals in 2010 that reached the third level of review, which are decided by an administrative law judge, were filed by health care providers. And for those who persevere and do appeal a third a third time, the OIG found that the judges reversed 56 percent of all unfavorable decisions in 2010.

How To File A Medicare Appeal

Read below news story.

Medicare officials this year redesigned the quarterly beneficiary statements to make instructions about the appeals process clearer, said an agency spokeswoman, who did not respond to requests for additional information.

Some problems can be resolved without appealing, said Mary Ann Parker, an attorney with the District's Long-Term Care Ombudsman Program, which advocates for nursing home residents.

Sometimes a payment is denied because the doctor or other provider used the wrong treatment or billing code. If the provider resubmits a corrected claim, it will most likely be paid.

Today's Related Headlines from KHN

The Center for Medicare Advocacy receives state funding to help Connecticut residents navigate the Medicare program, and handles several hundred of their appeals a year. Murphy said less than 10 percent of these cases overturned in the first and second levels of appeals. "It's almost an automatic denial," she said.

But at the third level of appeal, the center has won roughly 60 percent of its appeals in the past three years. "If people knew that they are likely to lose at the first couple of levels, they would stick it out until they got to a judge," Murphy said.

"The administrative law judge stage is the first level when you can interact with a human," said Diane Paulson, senior attorney at Greater Boston Legal Services, which handles about 50 appeals a year. The first two levels of appeals are based on documents only.

Driscoll thought his case was a slam-dunk. Following instructions on his quarterly Medicare statement, he circled the charges he was questioning and sent it to the Medicare contractor's address listed on the notice. When he was turned down, he tried again, this time including a letter from his doctor saying that the aneurysm test was medically necessary. He attached pages from the "Medicare & You" handbook that say Medicare covers the test. "There was a lot of back-and-forth," he says, that required him to call his physician and the radiologist who performed the test to collect additional information.

His appeal was turned down again. Driscoll said he was unable to find out why. But that was enough for him.

"I paid the bill and I gave up," said Driscoll, who at the time was in the process of moving and retiring from his job at a nonprofit agency. He paid the $214 charge last year. "I spent over a year on this thing, and it wore me out."

Janice Prokop-Heitman's mother didn’t have that kind of time. "My mom was in a nursing home in 2011 after she had a serious stroke," said Prokop-Heitman, who lives Plymouth, Mich., a Detroit suburb.

After about seven weeks, the home told Prokop-Heitman that her mother wasn’t responding to treatment and gave her 72 hours to move to another facility for custodial care. But there wasn’t time to find another facility and she didn’t want her mother "bounced from place to place." So she hired a former rehabilitative care nurse as a consultant to help prepare a fast-track appeal, which is decided sooner than a standard appeal.

"I was learning about this as I was doing it," she said but with the consultant’s assistance, she won the appeal. The nursing home was required to resume her mother’s speech therapy, while she and her sister-in-law looked for another facility and found one. "We were lucky," she said.


How to File a Medicare Appeal

Here are some basic steps for challenging Medicare coverage denials under Part A (including hospitalization, nursing homes and hospice services) and Part B (doctor visits, tests, home health care, durable medical equipment). In most cases, it is not necessary to hire a lawyer. Advocates say to be sure to write your Medicare or member number on all documents, and to keep copies.

For the first appeal, called redetermination:

--Circle the questionable item on your quarterly Medicare statement, called the Medicare Summary Notice, and follow the mailing instructions on the form. You can also complete an appeals form at www.medicare.gov/claims-and-appeals/file-an-appeal/original-medicare/original-medicare-appeals.html.

--Make the request within 120 days of receiving the denial.

--Any dollar amount can be appealed.

If you get denied again, you can make a request for second appeal, called reconsideration:

--Make the request within 180 days of receiving notice that the first appeal was denied.

--In a letter, explain the services or items that you received and why payment for them is in dispute. Include a copy of the initial denial or fill out the reconsideration form available at www.medicare.gov/claims-and-appeals/file-an-appeal/original-medicare/original-medicare-appeals-level-2.html.

More On Medicare Appeals

Seniors Need To Be Tenacious In Appeals To Medicare

To request a hearing before an administrative law judge, which usually is conducted via conference call with patients, doctors and others:

--Make the request within 60 days of receiving the denial of the second appeal.

--To be eligible for a hearing, the amount in dispute must be at least $130 in 2012 and $140 in 2103. In your letter, provide your name, address, Medicare number, document control number from previous denial, dates of services or items in dispute and why you are appealing. Include any other information to support your request, or complete a hearing request form available at www.medicare.gov/claims-and-appeals/file-an-appeal/appeals-level-3.html.

If you get denied again, you can make a request for consideration by the Medicare Appeals Council:

--Make this request within 60 days of receiving the hearing decision.

--In a letter, cite which parts of the decision you dispute and the date of the decision, or complete the hearing review request form available at www.medicare.gov/claims-and-appeals/file-an-appeal/appeals-level-4.html.

Beneficiaries who are still not satisfied can file an appeal in federal court. The amount in dispute must be at least $1,350.

Expedited Review

Patients may file an expedited appeal if they are being discharged from a nursing home, hospice, outpatient rehabilitation facility or told that home health care is being terminated (not reduced). Providers must give patients notice two days before discharge or termination. Information on this appeal is available at http://www.medicare.gov/claims-and-appeals/right-to-fast-appeal/non-hospital/fast-appeals-non-hospital-setting.html. Coverage for services will continue until a decision is made.

Patients who feel they are being discharged from the hospital too soon may get information about an expedited review of the decision at http://www.medicare.gov/claims-and-appeals/right-to-fast-appeal/hospital/fast-appeals-in-hospitals.html. Coverage for services will continue until a decision is made. (There is a separate procedure for Medicare Advantage plans.)

Medicare Advantage

Beneficiaries in Medicare Advantage plans follow similar appeals procedures, except the initial appeal must be made within 60 days of the denial. Information can be found at http://www.medicare.gov/claims-and-appeals/file-an-appeal/medicare-health-plan/medicare-health-plan-appeals.html. If a service or treatment has been denied, an expedited appeal can be requested from the plan if waiting for a regular appeal decision could jeopardize the member’s health. Expedited appeals are not permitted solely for payment denials. For more details about expedited Medicare Advantage appeals, see section 50 of the Medicare Managed Care Manual at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/mc86c13.pdf .

Prescription Drug Plans

Decisions made by Medicare prescription drug plans can also be appealed. Beneficiaries should request a written explanation from the plan why a prescription is not covered and ask for an exception if you or the prescriber believe you need the drug. Beneficiaries pay for the drug until the denial is overturned (during that time, drug discount cards or manufacturer or pharmacy discounts may reduce the cost). An expedited appeal is also an option for those who can't wait. More information is available at http://www.medicare.gov/claims-and-appeals/file-an-appeal/prescription-plan/prescription-drug-coverage-appeals.html.

For More Help

For free, individual assistance and more information, contact your State Health Insurance Assistance Program at https://shipnpr.shiptalk.org/shipprofile.aspx or find it by calling your county office on aging.

Additional details are at www.medicare.gov/claims-and-appeals and 800-MEDICARE (800-633-4227).

The Center for Medicare Advocacy's free self-help appeals packets include tips for avoiding appeals; they are available at www.medicareadvocacy.org/take-action/self-help-packets-for-medicare-appeals.

The Medicare Rights Center, a consumer advocacy group, provides appeals advice and other Medicare information at 800-333-4114.

This article was produced by Kaiser Health News with support from The SCAN Foundation.

We want to hear from you: Contact Kaiser Health News

Some of this information is reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. You can view the entire Kaiser Daily Health Policy Report, search the archives and sign up for email delivery. © Henry J. Kaiser Family Foundation. All rights reserved.

 

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