Medicare Appeals

You have the right to appeal any Medicare decision that negatively affects you. This is true whether you are in the Original Medicare plan or in a Medicare Advantage plan or Prescription Drug plan. If Medicare does not pay for an item or service you have received, or if you are not given an item or service you think you should get, you can appeal their decision. But here are some important considerations before you go down the appeal road yourself — it is a time-consuming, weighty process:

• Medicare cannot change your out-of-pocket costs for individual services under the program. These are mandated by Congress and cannot be changed. They are calculated automatically if your physician takes assignment.
  
• Check with your doctor before appealing. Many denials are just billing mistakes, even if Medicare says services are not necessary. Plus, your doctor may be appealing the claim anyway, and doctors do not usually notify patients about appeals. You do not want to compete with the billing doctor because that might confuse the issue and prevent a quick resolution.
  
• Most of the time, your doctor is your biggest ally in the war against Medicare. He or she has the clinical information, and that is the ammunition you need to get items or services paid. However, remember that Medicare’s bosses are in Congress. So, if you think the Medicare program has treated you very unfairly, you can contact your Representative or Senator or both. But be aware that you’d better be well prepared if you go to that step.
  
• You will not have to pay anything if you did not sign some kind of waiver, such as an Advance Beneficiary Notice. Your providers are liable for the charge if you did not sign to accept liability. There are exceptions to this, including if you are in the Medicare Advantage program and did not get a referral or authorization for a service.
  
• Laws take precedence. Do not go through the levels of appeal if you know you are going against a Medicare rule or law. Since the entire appeals process can take many, many months, going against a law may be just a waste of time.
  
• Your case will not set a precedent. Each case is considered an individual story by Medicare law. Being a crusader does not count for much here.
  
• There may be help and support for you in this process. Drug companies have special hotlines that support appeals. If this is not a drug appeal, see our Medicare Webography for cancer patient advocacy organizations. There are a bunch of them, and they want to help you.
  
• An appeal is not the proper vehicle to report Medicare fraud. Medicare fraud is a heinous crime that can be punished as a criminal offense. But let’s be reasonable — everyone makes mistakes. If you are billed for something in error, that is not fraud, and your doctor will be happy to refund the money. However, if you are repeatedly billed for something in error and your complaint is not heard, that may be fraud. To report suspected fraud, go to this website for step-by-step instructions.

Appeal Rights

• Special appeal rights for patients admitted in the hospital - This is true whether you are in the Original Medicare plan or a Medicare Advantage plan. If you are admitted to a Medicare participating hospital, you should be given a copy of  “An Important Message from Medicare.” It explains your rights as a hospital patient. If you are not given one, ask for it. If you ask for it, read it. The message tells you:
  • That you have the right to get all of the hospital care that you need, as well as any follow-up care after you leave the hospital.
    
  • What you should do if you think the hospital is making you leave too soon?
• Appeal rights under the Original Medicare plan - If you are enrolled in the Original Medicare plan, you can file an appeal if you think Medicare should have paid for, or did not pay enough for, an item or service you received. If you file an appeal, ask your doctor or provider for any information related to the bill that might help your case or gather data from your patient health record.
  
• Your appeal rights are on the back of the Explanation of Medicare Benefits or Medicare Summary Notice that is mailed to you from the contractor that handles bills for Medicare. The notice will also tell you why your bill was not paid. This is usually fairly cryptic, so you might want to ask your doctor for the reason and (again) ask if he or she is appealing the claim.
  
• Appeal rights under Medicare Advantage plans - If you are in a Medicare managed-care plan, you can file an appeal if your plan will not pay for, does not allow, or stops a service that you think should be covered or should continue. If you think waiting for a decision about a service could seriously harm your health, ask the plan for a “fast track” decision. The plan must answer you within 72 hours.
  
  The Medicare Advantage plan must also tell you in writing how to appeal. After you file an appeal, the plan will review its decision. Then, if your plan does not decide in your favor, the appeal is reviewed by an independent organization that works for Medicare. These organizations do not work for the plan. If you have other concerns or problems with your plan, which are not about payment or service requests, you also have a right to file a grievance. For example, if you believe your plan’s hours of operation should be different, you can file a grievance.
  
• Appeal rights under the Prescription Drug Benefit - You also have appeal rights under the prescription drug plan. Unlike Original Medicare, you must request the explanation in writing (coverage determination) when you are denied coverage due to a drug not being on a formulary or are asked to pay more than required for a specific prescription drug. Your plan has 72 hours to notify you of its decision, 24 hours for expedited requests. Check with your doctor about whether the request is considered standard or expedited. A sample form for requesting a coverage determination can be found here.

The Appeals Process

It is a big effort to appeal a denial, and you do not want to be involved in unnecessary work. AGAIN, lots of denials are just claim rejections for a billing mistake. However, though filing an appeal might seem hard at first, it’s worth the effort if you are out money or if your care provider is. A large number of appeals are successful. Your State Health Insurance Assistance Program (SHIP) can help with your appeal. Contact a SHIP office near you. Do not appeal without a “good” reason. Here are some examples of when to appeal:

• You don’t feel ready to leave the hospital. You are in the hospital after having lots of chemotherapy and you receive a notice from the hospital that Medicare will not pay for any more hospital days. Remember, Medicare will not allow a stay for your convenience. But if your doctor intimates that you are not ready to go, that is a different story.
  
• Your Medicare plan will not pay for a covered item or service you think you need. For example, Medicare won’t pay for genetic testing related to cancer, but both you and your doctor feel you need this test, since you have a family history of breast cancer. Or, a drug that you know that you need is not on your Medicare drug plan formulary and your doctor thinks you must have that drug.
  
• Your Medicare plan will no longer pay for health care you still need. For example, Medicare will no longer pay for your anemia drug, but you and your doctor feel that your anemia is going to return soon.

There are different appeals processes for the Original Medicare plan, Medicare Advantage plans, and Prescription Drug plans. A Medicare Advantage plan can be a Medicare health maintenance organization (HMO), a Medicare preferred provider organization (PPO), or a Medicare private fee-for-service (PFFS) plan.

For Original Medicare (Parts A and B), each of these steps must be completed in order, and you must pay attention to the time frames on the notice. Appeal forms can be found here. For all appeals you must have the following:

• The proper form from the web page above
• The item or service under dispute
• The date(s) of service being appealed
• All supporting clinical information from your medical record or personal health record
• Your Medicare number and signature
• An explanation of why this claim should be paid.

The Steps to Escalate Appeals

Appealing a denial of hospital, nursing home, or at-home care in Original Medicare (Part A) or doctor care in Original Medicare (Part B) all have the following basic steps. You cannot skip any of these steps.

1. Initial determination (denial notice) - You get an initial determination notice denying your care or refusing to pay for care. The denial notice will give you instructions on how to appeal and will include the filing deadlines. Make a note of them because you cannot forget deadlines. Once you receive the denial notice, you will have five sequential opportunities to appeal the denial. This can take considerable time and effort.
   
2. Redetermination - You can appeal to Medicare, asking them to review their decision. Ask your doctor to support your appeal by calling or writing to Medicare about your case. Redeterminations must be filed within 120 days of the initial determination. The contractor must respond within 60 days of receipt of your request for redetermination.
   
3. Reconsideration - You can ask Medicare to reconsider if you don’t agree with the redetermination, provided the request is filed within 180 days of redetermination. But you need to make sure that you have a substantial reason to go on. You might want to hire a lawyer or a patient advocate at this point. Qualified Independent Contractors (QICs) perform these reconsiderations.
   
4. Administrative law judge (ALJ) hearing - You can request a hearing with an ALJ if you don’t agree with the reconsideration decision. At least $110 must be in dispute in 2007. This must be filed within 60 days of the reconsideration decision and must be decided within 90 days of receiving the request for the decision. There are four ALJ sites in the entire United States; however, the majority of hearings will be conducted by videoconference or by telephone. You can see a judge, but there must be extraordinary circumstances.
   
5. Medicare Appeals Council (MAC), Department of Health and Human Services, Departmental Appeals Board (DAB) - You can appeal to the DAB if you don’t agree with the ALJ decision. This must be filed within 60 days of the ALJ decision, and the MAC must make their decision within 90 days of request, with some exceptions.|
   
6. Federal court appeal - You can appeal to a federal court if you don’t agree with the DAB decision. In 2007, the disputed amount must be at least $1,130. This request must be made within 60 days of the DAB decision.

Appealing in Medicare Advantage Plans

Nonurgent and Urgent

1. Organizational determination - Your plan must send you a written notice of their decision within 14 days for a request for health care (or authorization of same) — such as hospitalization — and within 30 days for a request for a payment. If your request is denied, the notice must include the reasons for the denial and instructions on how to appeal. But, if the determination interrupts your treatment, your plan must give you a decision within 72 hours.
   
2. Reconsideration - You can ask your plan to reconsider if you don’t agree with the organizational determination. Someone outside the plan must do this reconsideration to ensure that someone without a financial interest in the outcome hears your case.
   
3. Center for Health Dispute and Resolution (CHDR) - If your plan still denies the service or payment in whole or in part, it must send your appeal to the CHDR, an independent review group. Your plan must give you the name of the CHDR. If this is an urgent interruption of care and your plan still denies the service or payment in whole or in part, it must send your appeal to CHDR, which must make a decision within 10 days.
   
4. Administrative law judge (ALJ) - You can request a hearing with an ALJ if you don’t agree with the CHDR decision. At least $110 must be in dispute.
   
5. Department of Health and Human Services, Departmental Appeals Board (DAB) - You can appeal to the DAB if you don’t agree with the ALJ decision. You must appeal within 60 days of the disputed ALJ decision.
   
6. Federal court appeal - You can appeal to a federal court if you don’t agree with the DAB decision. At least $1130 must be in dispute.

Appealing Part D Prescription Drug Denial

1. Coverage determination - This is the explanation in writing from the plan for the denial (see earlier discussion under Appeal Rights).
   
2. Redetermination - If you disagree with the plan’s coverage determination, you must appeal within 60 days of that decision. Your plan will have 7 days for standard requests, or 72 hours for expedited requests, to make a decision.
   
3. Reconsideration by an independent review entity (IRE) - If you disagree with the appeal, you have 60 days to request review by an IRE. The IRE will have 7 days for a standard request, or 72 hours for an expedited request, to notify you of their decision. The IRE is Maximus CDRH.
   
4. ALJ hearing - You can request a hearing with an administrative law judge (ALJ) if you disagree with the IRE. As with the IRE, you have 60 days to make the request. The projected value (as determined by the IRE) must meet a minimum dollar amount ($110 in 2007). The ALJ has 90 days to render its decision.
   
5. Medicare Appeals Council (MAC) - If the ALJ upholds the decisions made by the IRE and your plan, you can request a review by the Medicare Appeals Council, which will make a decision within 90 days.
   
6. Federal court review - If all previous appeals fail, and the projected value of the claim (as determined by the MAC) meets a minimum dollar amount ($1,130 in 2007), you can request a federal court review.

Check with your Medicare Prescription Drug Plan for more information. Find a contact in your plan at this Web page.

Complaints

If your plan refuses to consider an expedited coverage determination or first-level appeal, or your plan does not make its coverage decision or first-level appeal in the required time, or even if your pharmacy wait time is too long, you may issue a complaint to your prescription drug plan. You should do this within 60 days. If your plan doesn’t address your complaint, you can call 1-800-Medicare.