Here at MedicarePhD we want you to understand that if you do not agree with a coverage or payment decision made either by Medicare or a private health plan, the system provides you the right to appeal. You can appeal if you are denied health care coverage or drugs, if you are not reimbursed for a medical expense, if you believe you are being overcharged for a drug, or if payment is discontinued for a medical service you feel you still require.
APPEALS
The appeal process can be challenging, but it is certainly worth the effort if you believe you are dealing with an inequity. The unfortunate reality is that most individuals do not appeal when some form of payment or coverage has been denied, even though an obvious injustice has occurred.
There are two forms of appeal situations; the first if you have Original Medicare and the second if you are with a Medicare Advantage or Prescription Drug plan. If you are with Original Medicare, there are 6 pages in Medicare & You under the section “Protecting Yourself and Medicare,” that describe exactly how to appeal a decision.
Individuals with a Medicare Advantage or Prescription Drug plan have a different procedure on appeals as they are challenging their insurance company, not Medicare. When you sign up for such a plan, you will receive a booklet called “Evidence of Coverage” and this will detail the steps you need to take. For example, the company I chose has a 16 page section on how to appeal, including 5 different options if you continue to be denied.
Since there are 6 pages of explanation in Medicare & You and 16 pages
in a private plan on how to appeal, you now realize why so few people go this route. You say to yourself this is not worth it to contest smaller charges under $100. Now consider what this means in profits if a company denies thousands of such claims and you readily comprehend why many claims in the “gray” area are denied.
Before you seek assistance, first try a simple phone call to your plan’s customer service department or to the Medicare Hotline (1-800-Medicare) and you may be able to resolve the issue. If you receive no gratification, you need to decide whether to proceed further, and this decision is primarily driven by the amount of money in question. I previously gave the example of $100, but quite commonly the amount in contention runs into the thousands. If this is the case, you need to consider the following avenues of assistance.
Go to Next Section:
The key here is perseverance and the appeals process is very doable. MedicarePhD does not want you to be a wuss and think you cannot possibly win against Medicare or a private insurance company. If for some reason you are physically unable to pursue the aforementioned actions, it is time for family or friends to assist you.
DO NOT GIVE UP!
• If you are enrolled in a private plan, the best source of assistance should be the agent who sold you the policy. Selecting the right plan is definitely the most important decision, but a close second is choosing the right agent. If you are required to go through the appeal process, you will quickly find out if your choice of agents was a good one.
They should be more than willing to assist you and deal directly with the company themselves, so hopefully you were a good judge of character. Unfortunately, many agents could care less once they sell you the policy and will just refer you to their company’s printed literature on how to proceed.
Another agent problem is the fairly high turnover ratio among this group so they may be long gone when you need appeal assistance. Thus, the longer your agent has been with the company, the better. (Yet another reason to select a company agent rather than an independent.)
Now if your agent turns out to be a real Bozo, don’t give up because we have further suggestions.
They should be more than willing to assist you and deal directly with the company themselves, so hopefully you were a good judge of character. Unfortunately, many agents could care less once they sell you the policy and will just refer you to their company’s printed literature on how to proceed.
Another agent problem is the fairly high turnover ratio among this group so they may be long gone when you need appeal assistance. Thus, the longer your agent has been with the company, the better. (Yet another reason to select a company agent rather than an independent.)
Now if your agent turns out to be a real Bozo, don’t give up because we have further suggestions.
• An excellent source of assistance with appeals is your State SHIP or SHINE organization that we discussed in the Financial Assistance section. In addition to providing assistance to low income seniors, they specialize in assisting you navigate the appeals process for both Original Medicare and private plans.
• OK, you tried calling customer service and received no satisfaction. Next, your agent has taken off to Key West and their return is very questionable. Third, SHIP and SHINE were not aggressive enough to resolve your problem. Is there an option out there other than the $400/hr attorney?
There certainly is as there are two advocacy organizations which may be able to provide very professional assistance at no cost. First, I would contact the Medicare Rights Center at 800-333-4114, and when prompted select the “Appeals Assistance” #3. This same hotline can provide you with financial assistance questions. If they are unable to assist you, and I do not believe this will be the case, contact the Center for Medicare Advocacy at 860-456-7790.
There certainly is as there are two advocacy organizations which may be able to provide very professional assistance at no cost. First, I would contact the Medicare Rights Center at 800-333-4114, and when prompted select the “Appeals Assistance” #3. This same hotline can provide you with financial assistance questions. If they are unable to assist you, and I do not believe this will be the case, contact the Center for Medicare Advocacy at 860-456-7790.
ASSISTANCE AVAILABLE
TWO APPEAL SITUATIONS
A CHALLENGING PROCESS
You can be sure the insurance companies, and even Original Medicare, know that very few people appeal and when making a decision will always err on the side of profit. Medicare literature is replete with case studies of inequitable denials, so DO NOT LET THIS HAPPEN TO YOU!
Copyright 2010 MedicarePhD.com Inc. All rights reserved
MedicarePHD.com is for informational purposes only and does not render legal advice.
If you have specific legal questions, please contact your attorney
