Bottom Line: Few people challenge denied claims, but most of those who do win!
Don’t grab your checkbook just because your Medicare Advantage Plan denies a claim. Not only do you have the right to appeal, chances are very good that you’ll win and coverage will be provided.
According to the US Office of Inspector General for the Department of Health and Human Services, Medicare Advantage plans routinely deny millions of claims every year, especially on the first go-round. When challenged, they reversed their decisions a whopping 75% of the time. But just 1% of denials are ever appealed—that means 99% of the time most people give up.
The government conducted an audit of Medicare Advantage plans’ denials and found that the number of claims being denied is so big that it recommended stronger oversight of these private plans by Medicare. But it’s still up to you to fight to have a denial overturned.
Medicare Advantage Plans, similar to HMOs or PPOs, want you to stay within their roster of providers because this is most cost-effective for them. No wonder the biggest reason for denying a claim is that you’re requesting or had care outside your plan’s network.
Here are common reasons for denial and what you can do about them…
If you went out of network in an emergency: Document your claim. Explain why, for instance, you went to an emergency department that’s not in your plan when you sliced your finger and not the urgent-care center near your home—maybe you were out of town visiting your son, it was late at night and it was your only choice. Search the Internet to list providers where you were and their hours. It will support your claim that the out-of-network ED was your only option at the time of your injury.
If you want to see a specialist or if you need a treatment not covered by your plan: For both of these situations, the answer is to ask your primary (in-network) doctor for help by putting in writing why he/she recommends this particular provider or treatment and what effect it will have on your condition. Ask your doctor for any studies that support his/her position, and include them in your appeal. Your health-care provider is your best spokesperson and should go to bat for you.
If a provider made a paperwork error: Sometimes the denial is for a simple and easily corrected problem, such as submitting the wrong code for a procedure or filling out your ID number wrong. Ask the billing office at your care provider to fix it and resubmit the claim. And follow up with the office in a week or two to make sure it was done and then follow up with your Medicare Advantage plan.
If your plan says no to a prescription drug: If the drug isn’t part of your plan’s formulary or if you haven’t tried (and failed with) other drugs it wants you to try first, ask your provider to explain in writing why this is the drug you need and must have.
The letter denying your claim, a “Notice of Denial of Medical Coverage,” must be sent to you within 14 days of a verbal denial and must explain why it was denied and provide forms and instructions for appealing the decision. Follow them precisely. These tips will also help…
Meet all deadlines. You must file your appeal within 60 days of receiving the denial notice. Don’t be late or you won’t have any recourse.
Keep meticulous records. Put your appeal in writing. Be sure to include your name, address, Medicare Advantage number and contact info on all correspondence. Include the health-care providers, addresses and contacts for the services you’re requesting or had. You don’t want your plan to use the excuse that it couldn’t review or reverse its decision because information was missing. Keep copies so that you can prove you supplied what they wanted when they ask, “Why didn’t you say that in the first place?”
Get the support of an advocate or advocacy group. As an example, if your doctor is recommending a treatment for your cancer that is not covered, contact the American Cancer Society. It may have information to support the success of this particular treatment. There is an advocacy organization for virtually every condition, even rare ones.
Speak up when you need a fast response. Appeals are often answered within 30 days, but if waiting that long could jeopardize your health, request that your appeal be expedited and make it clear why. This could get you an answer within 72 hours.
If your first appeal is denied, you can file as many four more appeals. The more you persist, the greater your chances of success. Your first appeal will typically be to the same group that initially denied your claim. But later appeals go before increasingly independent arbiters. Note: Some higher-level appeals will be heard only if your claim is greater than $160. Be sure to include any additional information that you or your doctor finds to support your case as you move up the appeals ladder. Note: You also can request that these appeals be expedited if fast action is necessary for your treatment.
The fifth and final round is the Federal District Court, and you’ll need to decide whether it is worth the cost of legal counsel to proceed. At the time of this writing, to file a federal dispute, the amount of the claim must be at least $1,600 and it must be filed within 60 days of the fourth denial. Learn more on the website MedicareInteractive.org.
