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Disputing a denied Medicare claim can be a frustrating process, but it’s important to advocate for yourself or your loved one if you believe the denial was made in error. A good guide to go by – ALWAYS dispute the first denial. Since many claims are auto-approved electronically and initially approved by a third party, there can be errors that happen in the process. Keep all doctor’s records/forms you collect from your appointments until you know that the claim has been approved. If you are handling/attending appointments for someone else, keep a notebook and record all interactions with the doctor’s office including names, dates, and issue (this will help you immensely if you need to ensure the office is doing their part of making follow-up appointments and billing correctly).
Here are steps you can take to dispute a denied Medicare claim:
Review the Explanation of Benefits (EOB): When Medicare denies a claim, they typically send you an Explanation of Benefits (EOB) that explains the reasons for the denial. This document is crucial in understanding why your claim was denied. Reasons a claim could be initially denied:
- Incorrect billing code was used
- Missing information from doctor’s office
- Service not medically necessary (always contest this)
Contact your healthcare provider: If you believe the denial is due to a billing error or a misunderstanding, reach out to your healthcare provider’s billing department. They can often help you resolve the issue by resubmitting the claim with the correct information.
Request a written appeal: If you still believe the denial is unjustified, you have the right to appeal the decision. The EOB should provide instructions on how to appeal, including the deadline for filing the appeal. It’s crucial to request a written appeal within the specified timeframe.
Complete the appropriate appeal form and include all pertinent documents. Medicare offers several levels of appeals, each with its own form.
Medicare Appeals Council (fourth level): If the Administrative Law Judge Hearing (known as an ALJ hearing) is not in your favor, request a review by the Medicare Appeals Council using the OMHA-100 form.
Judicial review (final level): If all else fails, you can take your case to federal court.
- Submit the appeal: Carefully follow the instructions on the appeal form and make sure to include all required documentation. Send the appeal to the address provided on the form.
- . Wait for a decision: After submitting your appeal, Medicare will review your case and make a decision. This process can take some time, so watch dates.
- Keep records: Maintain copies of all correspondence and documents related to your appeal. This will be helpful if you need to escalate the appeal to a higher level.
- Seek assistance if needed: If you’re having trouble with the appeals process, consider seeking help from a Medicare counselor, patient advocate, or legal assistance to ensure you navigate the process correctly. In the state of Ohio, you can contact the Office of Medicare Hearings and Appeals (OMHA).
Remember that persistence is necessary when disputing denied Medicare claims. If your appeal is denied at one level, you can continue to pursue further appeals until you receive a favorable outcome or reach the final level of judicial review. All Medicare Advantage and Medicare Supplement (Medigap) plans have succinct appeals processes that all the carriers must publish and abide by. Those details are in each plan’s “Evidence of Coverage” document. Be sure to read it and . . . don’t give up!
Susan Allard is an SRES® (Senior Real Estate Specialist), Senior Placement and Eldercare Consultant who draws on her diverse background to provide professional and thoughtful solutions to empower you through your retirement journey. Contact Susan today.
