Medicare denials rarely challenged

Susan Jaffe / Kaiser Health News /


Published Dec 27, 2012 at 04:00AM / Updated Nov 19, 2013 at 12:31AM

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. Driscoll, 68, had the test done and was surprised when he got a bill from Medicare for $214.

Based on everything he had read from Medicare, he was sure this was a covered service. 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. 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 this year redesigned 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 Washington'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.

Murphy said less than 10 percent of the several hundred denials that her organization handles each year for Connecticut residents are 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 said, which 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.”

How to challenge a Medicare denial

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.

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 $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.

Medicare Advantage

Beneficiaries in Medicare Advantage plans follow similar appeals procedures, except the initial appeal must be made within 60 days of the denial.

Medicare prescription drug plans

Decisions made by drug plans can also be appealed. You should request a written explanation from the plan for why a prescription is not covered and ask for an exception if you or the prescriber believe you need the drug. You would pay for the drug during the appeal, but you should keep receipts: If the denial is overturned, the drug plan will reimburse for its share of the bill. (While an appeal is under way, drug discount cards or manufacturer or pharmacy discounts may reduce your costs.)

For more help

For individual assistance and more information, contact your State Health Insurance Assistance Program at https://shipnpr.shiptalk.org/shipprofile.aspx. 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.