Medicare Denials and Appeals

Often times, when you are injured, you may have to seek for coverage for your injuries through Medicare. Unfortunately, coverage may not be granted. Medicare denials occur when Medicare does not pay for a service rendered or a good provided to an individual who receives Medicare as payment for medical services. Frequently, Medicare denials arise where Medicare determines that the treatment rendered was not based upon “medical necessity.”

Moreover, a denial can arise if the health care provider is not enrolled in Medicare.  Additionally, if a medical office has improperly coded a bill submitted on behalf of the patient, Medicare may deny payment.

Time Reasons

Finally, Medicare denials can occur if a patient has utilized the maximum benefit allowed. For example, if there is a certain amount of time permitted for a hospital stay and this amount of time is utilized but the patient remains admitted in the hospital, Medicare may deny the additional time the patient stays at the hospital.

Appeals Process for Medicare Denials

When an individual who receives Medicare receives Medicare denial notices, the individual can file Medicare appeals.  Thus, any person who receives a denial from either Medicare, Medicare Managed Care or a Medicare Prescription Drug Plan can request either a standard or expedited appeal.

This appeal can be in writing or if the denial notice indicates that telephone appeals are permitted, you can do so via phone. The appeal can be filed by the patient, a physician or a patient’s authorized representative.  If expedited, Medicare has to answer you within seventy two hours.

Standard Appeals

A standard appeal requires an answer in seven calendar days.  Thereafter, if you still wish to appeal, you must put your appeal in writing and submit the appeal to an Independent Medicare Entity, otherwise known as an “IME,” which will then review the previous determination. The same time lines apply to the IME’s rendering of the decision. If denied, you may be able to request a hearing with an Administrative Law Judge. This request must be made in writing within sixty days of the decision by the IME.

Hearings for Appeals: Denial Amount Requirement

However, in order to obtain a hearing, the amount of the denied coverage must meet a certain dollar amount. This dollar amount is specified in the IME’s decision. If you are still unsatisfied after the Administrative Law Judge’s decision, you may be able to appeal to the Medicare Appeals Council if you meet a certain dollar amount and apply within sixty days of the decision.  This dollar amount is a specific amount of denied coverage specified in the Judge’s decision.  If you meet this amount, the Medicare Appeals Council will hear your case.  Thereafter, if you are still dissatisfied, you may be able to appeal to the federal court.  However, you must meet the dollar amount threshold, which will be contained in the Medicare Appeals’ Council’s decision.  You must also file this appeal within sixty days of this decision.  Once you have filed this federal court appeal, you have exhausted your appeals remedies.

How a Lawyer is Helpful

When confronted with a Medicare denial and appeal, one must handle a significant amount of paperwork, procedures and time deadlines.  The use of a Medicare attorney can reduce the stress, time and financial resources one must devote to the matter.  In addition, a Medicare attorney will utilize not only their skill but also their resources in order to obtain the most beneficial results for the Medicare recipient.