If a beneficiary disagrees with a decision, there are reconsideration and appeals procedures within the Medicare program.
Medicare approvals can be tough at times, and some may find their claims come up with the big "D" – denial. So what happens when Medicare denies a beneficiary’s claim for care?
While it is not always smooth sailing, it is important to know that you are not without recourse. You can appeal Medicare decisions to refuse coverage for needed care, and sometimes you simply must.
Claim denial is a pretty sticky situation. When you cannot navigate your way through a change of care or providers, or if you have been stuck with a bill that truly ought to have been covered, you can appeal by following a few stages. ElderLawAnswers recently updated its handy guide not too long ago, providing an answer to the question “Can You Appeal If Medicare Refuses to Cover Care You Received?”
Essentially there is a Medicare review process. Through this process the federal government works with the intermediaries involved to sort out the problem (e.g., it could be as simple as a billing code error). If no relief is obtained, then the matter can be brought to court if the amount in question exceeds $1000 to $2000 (yes, the amount varies depending on the claim itself). While no one relishes a trip to the courthouse, you can either represent yourself, be represented by a personal representative, or even be represented by your own attorney.
A helpful statistic: “The Medicare Rights Center estimates that only about 2 percent of Medicare beneficiaries appeal denials of care, but 80 percent of those who appeal Part A denials and 92 percent who appeal Part B denials win more care.”
Reference: ElderLawAnswers (mod. December 19, 2013) “Can You Appeal If Medicare Refuses to Cover Care You Received?”