Senior Help Forum » appeals

The Best Way to Win an Insurance Appeal

awhite — Fri, 08 May 2009 12:56:09 +0000

The punchline is, “Not to have to do one.”

We’ve posted before on Medicare insurance appeals for Part A/B, Medicare Advantage, and Part D. We’ve even posted on doing battle with insurance companies. The fact is, insurance appeals are time consuming and can feel like doing battle. If you can avoid one, why wouldn’t you? How likely is that you’ll have to appeal an insurance/Medicare decision? I don’t have the statistics, but I suspect that most will do it in their lifetimes. If you haven’t had to appeal, ask a couple of people. Odds are they have.

If you believe that there’s a chance that you’ll want to appeal in the future, why not reduce that chance by spending some time understanding your coverage and what it takes to avoid the calls and letter writing? Consumers Union and The Henry J. Kaiser Family Foundation did, “A Consumer Guide to Handling Disputes with Your Employer or Private Health Plan, 2005 Update” that’s all about how to deal with problems with your insurance. But the gem in there is, “a checklist for diagnosing your coverage”

The checklist covers many of the triggers that will put you in a situation for an insurance appeal. For instance, it asks you to check the medical services for which you need a referral from your primary-care physician. Sure you may know some of them, but if you dig through your insurance coverage forms and identify them in advance, you’ll reduce the chance of a denial of coverage.

There are a number of checklists that you’ll want to fill out:

My primary-care physician has the following requirements for obtaining referrals
My primary-care physician can refer me to specialists who
I have reviewed the Exclusions and Limitations section in my Evidence of Coverage. My health plan will not pay for, or limits, the following services
My plan will cover services at the following hospitals
What should I do if I need care while I am out of my plan’s service area?
Although I can use out-of-network doctors for most services, I cannot use out-of-network doctors for the following services
If I use out-of-network providers, I will pay

So, here’s what you need to do:

Print the form a checklist for diagnosing your coverage
Fill out what you can from reading your plan
Call your plan provider for the information you don’t have

This won’t guarantee that you won’t have a reason to appeal, but it should give you some peace of mind that you’ve reduced your chances a denial.

And, if you do have to appeal:

How to Appeal Medicare Part D prescription drug coverage denial

awhite — Wed, 11 Mar 2009 11:30:28 +0000

Note: This is the third part of a three-part post on Medicare appeals.

Medicare Part D appeals are similar to those for Medicare Advantage, but have some distinct differences. In this post, we’ll use Part D to cover both standalone Part D prescription plans and prescription plans that are part of a Medicare Advantage plan, often referred to as MADP. As with Medicare Advantage, Part D appeals are different from those of Medicare Part A/B in that you’re appealing to the independent company that provides your Medicare benefits. You’ll need to contact your provider and ask about the appeals process. Most have information on appeals on their websites, including official forms. Your initial appeal is with your provider. If you’ve read the previous posts, you’ll know that there are multiple levels of appeals available to you.

Again, as with other appeals, the first thing you have to do is decide whether you want to take on an appeal on your own. We recommend educating yourself about the process, AND getting help. Consider contacting a State Health Insurance Assistance Program (SHIP) counselor. They’re trained to help in Medicare issues. A friend, family member, or attorney can also be named as a representative using the Medicare Appointment of Representative form.

You should also talk to your doctor to determine if there is a different drug that you can take that is covered by your plan.

So, in what situations would you consider appealing to a Part D or MADP plan? Generally, Part D appeals stem from you wanting:

a drug that is not on the formulary (covered medicines)
a drug that is excluded from Medicare coverage by law
a drug that is not “preferred” by your Medicare private drug plan
a dosage amount or formulation that is not approved on the formulary
a lower co-payment coinsurance for a particular drug

In order to start the appeal, you’ll need the written ‘coverage determination’ from your plan before you can start the appeals process. Coverage determination simply means that your plan has said whether, or not, they’ll cover a particular medication. That should only take 72 hours, or 24 hours if an expedited request is made. Of course, only a negative determination will lead you to an appeal. You’ll need a doctor’s statement explaining the medical necessity of your prescription. According to Medical Rights Center, “Your doctor’s letter must assert that the prescribed drug is medically necessary and:

Any drug on the formulary would not be as effective and/or would be harmful to you.
All other drug or dosage alternatives on the plan’s formulary have been ineffective or caused harm, or based on sound clinical evidence and knowledge of the patient, are likely to be ineffective or cause harm.

While your plan must accept any written request and cannot require you to use a specific form, it is best to use the coverage determination request form provided by Medicare.

If someone other than the member is making the request, documentation identifying the individual’s authority to act on behalf of the member, such as a completed “Appointment of Representative” form must be included.

If the plan denies the request for reconsideration, you can appeal to the Independent Review Entity (IRE) for review. For Medicare Part D, Maximus Federal Services is the IRE. If the IRE didn’t rule in your favor, you still have three additional levels of appeal.

Hearing with an Administrative Law Judge
Review by the Medicare Appeals Council
Review by a Federal court

If you haven’t contacted a SHIP counselor, or another professional specializing in Medicare appeals, now is the time. As we’ve said before, why forego free help in the first place? If you want to understand the details of the Medicare Part D appeals process, check out this section of Medicare’s site.

How to Appeal Medicare Advantage/HMO coverage denial

awhite — Tue, 10 Mar 2009 11:16:33 +0000

Note: This is the second part of a three-part post on Medicare appeals.

Medicare Advantage (formerly Medicare Part C, and often referred to as a Medicare HMO) appeals are different from those of Medicare Part A/B in that you’re appealing to the independent company that provides your Medicare benefits. You’ll need to contact your provider and ask about the appeals process. Most have information on appeals on their websites, including official forms. Your initial appeal is with your provider. We say initial here because as with most appeals processes, they can have multiple levels.

The first thing you have to do is decide whether you want to take on an appeal on your own. We recommend educating yourself about the process, AND getting help. Consider contacting a State Health Insurance Assistance Program (SHIP) counselor. They’re trained to help in Medicare issues. A friend, family member, or attorney can also be named as a representative using the Medicare Appointment of Representative form.

You may see the term ‘organization determination’ in relation to the appeals process. Organization determination is simply the initial decision about whether the provider will cover the medical care or service you request, or pay for a service you have received. Providers routinely make the organization determination when your physician submits a charge for payment. A plan must respond to the request within 14 days of receipt, unless an extension is required. There’s also what’s known as an ‘Expedited Organization Determination”, which is usually made when a longer delay could potentially jeopardize the life, or health, of the member. In these cases, a response in 72 hours is required. If the request is denied by the plan, the member should be notified in writing the reason for the denial and advised of further appeal rights.

So, when you’re provider denies payment for a treatment, you have the option to appeal. You, or your representative, must appeal in writing within 60 calendar days from the date of the notice of the organization determination. Your appeal must include:

The member’s name and address
The health insurance claim (HIC) number
The specific service and/or item(s) for which a reconsideration is being requested, including dates of service
The reasons for appealing and any evidence the member wishes to attach
The member’s signature or that of the appointed representative

An appeal will be expedited and a decision made within 72 hours if a physician, orally or in writing, supports that the standard time frame for a grievance or appeal would seriously jeopardize the life or health of the member, or would jeopardize the ability to regain maximum function.

So, what if the plan again denies the request for reconsideration? The appeal should automatically be sent by your plan provider to an Independent Review Entity (IRE) for review. The review will be expedited if the IRE determines that your life or health may be seriously jeopardized by waiting for a standard decision. You may submit additional information to the IRE. The IRE must receive the information 10 days after receipt of the IRE letter acknowledging receipt of the case file. A copy of the submission must be provided to the plan.

If the IRE didn’t rule in your favor, you still have three additional levels of appeal.

Hearing with an Administrative Law Judge
Review by the Medicare Appeals Council
Review by a Federal court

If you haven’t contacted a SHIP counselor, or another professional specializing in Medicare appeals, now is the time. As we’ve said before, why forego free help in the first place? If you want to understand the details of the Medicare Advantage appeals process, check out this section of Medicare’s site.

In the next post, we’ll cover Medicare Part D appeals.

Turned down for a Medicare Part A/B medical expense? Appeal! Here’s how.

awhite — Mon, 09 Mar 2009 11:03:24 +0000

Note: This is the first part of a three-part post on Medicare appeals.

Has Medicare, a Medicare Advantage, or a Medicare Part D plan turned you down for an expense that you think should be covered? As long as you honestly believe that you the expense should be covered, you should appeal. Definitive statistics are hard to come by, but most claim that more than half of all appeals succeed.

We’ll cover Medicare appeals in three posts because the approach differs for appealing a Part A/B from Medicare Advantage and Part D. This post covers Medicare Part A coverage of in-patient hospital stays, skilled nursing home care, home health care, and hospice care, and Part B coverage of doctor’s services, out-patient hospital care, and other services not covered by Medicare Part A. If you were turned down for payment for a medical procedure, or a doctor’s prescription, by a company that provides coverage under a Medicare Advantage plan, or a Medicare Part D plan, the appeals process is different and we’ll cover that in the next posts.

As with many things related to insurance, it’s often best to get help. Consider contacting a State Health Insurance Assistance Program (SHIP) counselor. They’re trained to help in Medicare issues. A friend, family member, or attorney can also be named as a representative using the Medicare Appointment of Representative form.

Under the Part A/B, if you think Medicare should have paid for, or did not pay enough for, an item or service you received the appeal process is relatively straightforward. Your right to appeal is explained on the back of the Medicare Summary Notice (MSN) (PDF). You should get the MSN every 3 months from the company that handles Medicare claims. The MSN should explain why Medicare won’t pay for an item or service and how to file an appeal. If you file an appeal, it’s important to ask your doctor or provider for any information that might help your case. The steps to filing an appeal for Medicare Parts A and B are typically:

Circle the items that you disagree with
Explain why you’re appealing
Sign the MSN and include your phone number
Send it to the Medicare contractor identified in the “Appeal Information” section of the MSN
Include documentation, such as a letter from your doctor that you feel supports your appeal

Make sure that you file the appeal within 120 days of receiving the notice. Sometimes the language can get a little tricky. What you’re actually doing is filing for ‘redetermination’. The notice that you first received that said that a medical claim is denied is the ‘determination’. The redetermination request must be filed with the company that handles Medicare claims as indicated on the MSN. There is no minimum dollar amount that must be in question for you to request a redetermination. The company that handles your Medicare claims should send you a written decision within 60 days of getting your request.

There’s a Medicare Redetermination Request Form (PDF) available on the Centers for Medicare and Medicaid Services site that’s helpful in getting the pertinent information on paper.

Okay, so what if they don’t find in your favor? There are actually four formal levels of appeal that go like this:

Second Level of Appeal – Reconsideration
Third Level of Appeal – Administrative Law Judge (ALJ) Hearing
Fourth Level of Appeal – Medicare Appeals Council (MAC) Review
Fifth Level of Appeal – Federal Court Review

If you haven’t contacted a SHIP counselor, or another professional specializing in Medicare appeals, prior to filing for redetermination and have been turned down, now is the time. Why forego free help in the first place? If you want to understand the details of the Medicare Part A/B appeals process, check out the document on the Medicare site called, How to File a Medicare Part A or Part B Appeal in the Original Medicare Plan (PDF).

The next post is on Medicare Advantage appeals.

Senior Help Forum » appeals

The Best Way to Win an Insurance Appeal

How to Appeal Medicare Part D prescription drug coverage denial

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How to Appeal Medicare Advantage/HMO coverage denial

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Turned down for a Medicare Part A/B medical expense? Appeal! Here’s how.

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