How to fight back and win

Many seniors assume that they have no choice but to pay when their Medicare claims are declined in whole or in part. In fact, denied or underpaid claims can be appealed — and more than half of these appeals are successful.

APPEALS THAT WORK

When your Medicare claim is denied or approved for less than the full amount, you have 120 days to request a “redetermination” of the decision. The Medicare Redetermination Request Form (Form CMS-20027) is available on the Medicare and Medicaid Web site (www.cms.hhs.gov/cmsforms/downloads/cms20027.pdf) or by calling 800-633-4227.

The written claim denial that you originally received includes instructions for where and how to submit this form. The claim denial includes an explanation as to why your claim was denied or why payment for your treatment wasn’t covered in full. You will need to contest this explanation to win your appeal. Ask your doctor to write a letter responding to the points raised in the denial and explaining why the health care is necessary. Include a copy of this letter with your appeals form, and keep a copy for your records.

Common reasons for denial of treatment and how to fight them…

REASON FOR DENIAL: The treatment, prescription or medical service is unlikely to cause your health condition to improve. (The denial likely falls into this category if the notice you received includes words or phrases such as “stable,” “chronic,” “not improving” or “no restorative potential.”)

How to fight: The Medicare program is required to look at your total condition and health-care needs, not just a specific diagnosis or your chance for full or partial recovery. Ask your doctor to write a letter explaining why the medical care is needed.

Example: Medicare denied home health care to a patient with Lou Gehrig’s disease, an incurable degenerative condition, because the care would not help her improve. The patient successfully appealed, arguing — with her doctor’s help — that while having a nurse visit her home would not improve her condition, it could slow the disease’s progression and is needed to otherwise care for her various health issues.

REASON FOR DENIAL: You are likely to require care for a very long time… or have already received treatment for a very long time without a resolution of the problem.

How to fight: Point out that Medicare coverage is not limited to treatments that work quickly. As long as your doctor continues to order this treatment for you, Medicare should continue to cover it. Include a letter from your doctor explaining that the treatment is having some positive effect or expressing an expectation that it will. (Medicare rules do limit how many days’ coverage is available in a nursing home or a hospital but not for home care.)

REASON FOR DENIAL: You do not qualify for Medicare-covered home care because you are not homebound.

How to fight: According to Medicare rules, “homebound” does not mean that you are completely unable to leave your home, nor does it mean that you are confined to a bed. You can be considered homebound even if you leave your home to obtain medical care or attend occasional family gatherings. You must require assistance and considerable effort to get out of the house.

Ask your care provider (which could be a family member, a home health professional or a doctor) to write a letter describing in detail how difficult it is for you to leave your home, and include this with the appeals form.

REASON FOR DENIAL: The dosage level of a prescription is greater than the dosage normally prescribed… or the drug prescribed is not normally prescribed for your health problem.

How to fight: Have your doctor write a letter explaining why the unusual dosage or drug is medically necessary for you. If possible, have the doctor cite published reports of similar usage.

Example: Your doctor might explain that you are allergic to the drug normally prescribed for your health problem.

REASON FOR DENIAL: Technical errors were made in the original Medicare claim. The rejection might cite a “coding error” or “incorrect Medicare recipient number.”

How to fight: Ask the health-care provider that submitted the claim to correct the problem and resubmit.

DON’T GIVE UP

If your Medicare appeal is denied, you have the right to file as many as four more appeals. Your odds of success improve the further you pursue the fight. While the initial “redetermination” appeal is made to the same group that initially denied your claim, later appeals are made to increasingly independent arbiters.

Appeal #2: You have 180 days from the date your redetermination request is denied to request that a Qualified Independent Contractor (QIC) make a “reconsideration determination.” You will have to complete the Medicare Reconsideration Request Form (Form CMS-20033, available at www.cms.hhs.gov/cmsforms/downloads/cms20033.pdf).

If the redetermination denial includes any reasons for denial not mentioned earlier, ask your doctor to write a new letter. Otherwise, attach a copy of your doctor’s earlier letter.

Appeal #3: If your second appeal is denied as well and the amount in dispute is at least $120 ($200 for a hospital inpatient claim), then you have 60 days to file a third appeal, this time with an Administrative Law Judge (ALJ) of the US Department of Health and Human Services. Filing instructions are included with the denial.

ALJ appeals are presented to the judge via telephone (or videoconference if you have the necessary technology). At the beginning of the hearing, confirm that the judge has a copy of any letters of support written by your doctors. Then explain your situation and why you require the care in dispute.

Helpful: Judges are supposed to rule based on the evidence and the law, but they are human. It never hurts to remind the judge that you are living on a fixed income and that you would face major financial problems or even health problems if Medicare fails to pay this bill and/or approve the treatment.

Appeal #4: If the judge turns down your third appeal, you have 60 days to request that the Medicare Appeals Council (MAC) review the decision. The ALJ denial will include instructions on how to do this.

Appeal #5: If the MAC turns down your appeal, you have 60 days to determine if you wish to hire an attorney and file a judicial review in Federal District Court. The amount in dispute must be greater than $1,180 ($2,000 for a hospital inpatient claim) to qualify. (This amount may change each year.) For more information, contact the Department of Health and Human Services at 877-696-6775 or www.hhs.gov/omha.