How to fight a Medicare claim rejection

Source: MARKETWATCH

By Anne Tergesen

Last Update: 4:56 PM ET Oct 23, 2012

Families that appeal a no-pay decision succeed surprisingly often, and can save thousands of dollars in medical expenses.

Last Monday marked the start of Medicares annual open enrollment season, a seven-week period that runs through Dec. 7 during which Medicare beneficiaries can add, drop, or switch medical and prescription-drug plans. For older Americans and their families, its a crucial opportunity to save money on the coming years health expenses.

But for many families, an equally important strategyand one that most beneficiaries dont pursueis appealing denied medical claims. As I reported in the Wall Street Journal this week, Medicare rejected at least 107 million claims in 2010 alone, leaving beneficiaries with billions of dollars in unexpected bills. But the small percentage of patients who appealed those denials succeeded at a surprisingly high rateas high as 53% for those who challenged rejections of payment for doctors visits and others services covered under Medicare Part B.

Knowing how to appeal one of these decisions, of course, is a responsibility that often falls on the adult children of an ailing senior and one that can have a big impact on a familys financial health. The exact procedure to follow varies, depending on whether you are enrolled in original fee-for-service Medicare, a Medicare Advantage plan administered by a private insurance company, or a Part D prescription-drug plan. My Wall Street Journal article includes a chart that offers a summary of the appeals process under original Medicare.

For filing appeals under a federally subsidized Advantage plan, which typically operates like a health-maintenance or preferred-provider organization, a great resource is Medicare Appeals, a brochure published by the Centers for Medicare & Medicaid Services, which administers the federal health care program. That same brochure also contains detailed, step-by-step instructions for filing appeals under Medicare Part D prescription drug plans.

If you need help appealing a hospital discharge, visit www.medicareinteractive.org, a web site of the nonprofit Medicare Rights Center. (This site also features detailed information on appealing claims under original Medicare, Medicare Advantage, and Part D prescription-drug plans.)

Yet another set of rules applies to those with original Medicare who wish to contest a decision to end care by a home health agency, skilled-nursing facility, hospice agency, or outpatient rehabilitation facility. A good resource here is the web site of the nonprofit Center for Medicare Advocacy, which publishes self-help packets on appealing denials of skilled nursing, home-healthcare, and outpatient physical therapy. (To find them, go to the Take Action tab at the top of the sites home page.)

If your initial appeal isnt successful, you can keep appealing--typically, each appeal can be heard up to five times. The final appeal takes place in a federal district court.

Those who go beyond the second step of the appeals process may benefit from retaining an attorney or medical advocate or seeking help from a nonprofit that provides free counseling, says Doug Goggin-Callahan, director of education at the Medicare Rights Center.

The following resources may help:

  • The Medicare Rights Center: Free consultations to callers at 800-333-4114.
  • The State Health Insurance Assistance Program: A free federally funded program that provides one-on-one consultations in person or on the phone.
  • National Association of Healthcare Advocacy Consultants (nahac.com): This is an umbrella group for medical advocates, who typically charge from $60 to $250 an hour.

Note: links have been removed from this article.

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