Health Column: Don’t take no for an answer from Medicare; appeal

07/06/2011 10:51 AM |

Dear Marci,
Original Medicare won’t pay for a health care service I received. What can I do?
Xiang

Dear Xiang,
If Original Medicare will not pay for care you received, you will find this out when you receive your Medicare Summary Notice. If you think the care you received is medically necessary, you should not take no for an answer.
• Find out if it is possible that there was a billing mistake. Sometimes providers accidentally use the wrong service codes when filling out Medicare paperwork and this can result in Medicare denials. A denial can sometimes be easily resolved by asking your doctor to double-check that your claim was submitted with the correct codes. If the wrong code was used, ask your doctor to resubmit the claim with the correct code.
• If the provider believes that the claim was correctly coded or is unwilling to re-file the claim, your next step is to appeal. The Medicare Summary Notice will have instructions for how to appeal. Follow these instructions and then mail the signed original to Medicare at the address on the MSN. Make sure you request your appeal within 120 days of receiving the MSN. If possible, get a letter from your health care provider saying that you needed the service and why and send this with your MSN.
Keep photocopies and records of all communication with Medicare, whether written or verbal, concerning your denial. Send your appeal by certified mail or delivery confirmation.
You can’t appeal to Medicare to cover services or items that are never covered, such as hearing aids.

Dear Marci,
My provider just asked me to sign an Advance Beneficiary Notice. What does this form do?
Marjorie

Dear Marjorie,
An Advance Beneficiary Notice (ABN), also known as a “waiver of liability,” is a notice that suppliers and other medical providers are required to give you when they offer you services or items that they know or have reason to believe Medicare will determine to be medically unnecessary for you, and therefore, will not cover.
Providers are not required to give you an ABN for services or items explicitly excluded from Medicare coverage. In addition, ABNs apply only if you are in Original Medicare, not if you are in a Medicare private health plan such as an HMO or PPO.
If you do not get an ABN to sign before you get the service or item from your provider, it’s not specifically excluded from coverage, and Medicare does not pay for it, then you don’t have to pay for it. You may need to file an appeal to show that you should not have to pay.
If the provider does give you an ABN that you sign before you get the service or item, and Medicare doesn’t pay for it, then you will have to pay your provider for it.
There will be an option on the ABN to check whether or not you want your doctor to submit a claim to Medicare for the service. You should always select that you want your doctor to submit the claim to Medicare. If you don’t, your doctor isn’t required to submit the claim. You should check this option, because Medicare may still pay for the services after all.
If you sign an ABN but ask your doctor to bill Medicare and Medicare then denies coverage, you can always appeal.

Dear Marci,
How does Medicaid work with Medicare to cover my health care costs?
William

Dear William,
All states offer a variety of Medicaid programs, and several can help people with Medicare. If you qualify for a Medicaid program, Medicaid can help pay for costs and services that Medicare doesn’t cover.
For services that both Medicare and Medicaid can cover — such as doctor visits, hospital care, home care and skilled nursing facility care — Medicare will pay first and Medicaid will pay second by covering your remaining costs, such as Medicare coinsurances and copayments.
If you have Medicare and Medicaid, you should be able to go to any doctor or provider who takes Medicare, Medicaid or who is in your Medicare private health plan’s network without having to pay the Medicare coinsurances or deductibles. You may still have to pay the Medicaid copayment for the service, depending on the rules in your state. However, if you go to see a provider who takes Medicare and Medicaid, the provider is most likely to bill correctly.
Medicaid can cover much more long-term care than Medicare does. Medicare requirements for coverage of long-term care services, such as home care and skilled nursing facility services, are generally stricter than Medicaid’s and the coverage itself is much more limited.
Medicaid will also pay for medical services not covered at all by Medicare as long as they are covered by Medicaid. Such services may include routine dental services and transportation to and from doctor appointments.
If you have both Medicare and Medicaid, Medicare, not Medicaid, will cover your drug costs. Having Medicaid will automatically qualify you for Extra Help, the federal program that helps with the cost of Medicare prescription drug coverage (Part D).

Marci’s Medicare Answers is a service of the Medicare Rights Center, the nation’s largest independent source of information and assistance for people with Medicare.