How to Appeal: What to Do if Your Medicare Plan Won't Pay

How to Appeal: What to Do if Your Medicare Plan Won't Pay
http://www.aarp.org/health/medicare/traditional/a2003-05-06-howtoappeal.html

There are times when your Medicare plan may refuse to provide a service or reduce or end care you think you need. No matter which Medicare plan you are in, you always have the right to ask your plan to review its decision by filing an appeal.

Here are some examples of when to appeal:

You don't feel ready to leave the hospital.
You are in the hospital recovering from knee replacement surgery and you receive a notice from the hospital that Medicare will not pay for any more hospital days.

Your Medicare plan will not pay for health care you think you need.
Medicare won't pay for a bone density test. Both you and your doctor feel you need this test, since you have a family history of bone fractures.

Your Medicare plan will no longer pay for health care you still need.
Medicare will no longer pay for your physical therapy. Both you and your doctor believe you can still need therapy to walk up and down stairs. Filing an appeal might seem hard at first, but it's worth the effort. A large number of appeals are successful. Your State Health Insurance Assistance Program (SHIP) can help with your appeal.

There is an appeals process for the Original Medicare Plan and an appeal process for Medicare + Choice Plans. A Medicare + Choice Plan can be a Medicare Health Maintenance Organization (HMO), a Medicare Preferred Provider Organization (PPO) or a Medicare Private-Fee-for-Service (PFFS) Plan.

The appeals process for the Original Medicare Plan outlined below. The first list shows the process to follow if you are denied care while in a hospital or a skilled nursing home or for a home health service (Medicare Part A).

The second list shows the process to follow if you are denied doctor care (Medicare Part B). Though very similar, there are some slight differences between Part A and B. In 2000, Congress passed a law that included the creation of one appeal process for Part A and B. When this part of the law goes into effect, there will be one appeals process for hospital, skilled nursing home, home and doctor care.

Appealing a Denial of Hospital, Nursing Home or at Home Care in Original Medicare (Medicare Part A)

There are some slight differences in the appeal process of a hospital, nursing home or home care. However, all have the following basic steps. Carefully watch how long you have to complete each step of the appeal.

Denial Notice. You get a notice denying you care or refusing to pay for care. (Be sure to get the denial in writing). The denial notice will give you instructions on how to appeal and will include the filing deadlines.

Initial Determination (Review) You can appeal to Medicare, asking them to review their decision. Ask your doctor to support your appeal by calling or writing to Medicare about your case. (If you are in a hospital, you can request an urgent review. See "Filing an Urgent Hospital Appeal

Reconsideration You can ask Medicare to reconsider if you don't agree with the initial decision.

Administrative Law Judge (ALJ) Hearing You can request a hearing with an ALJ if you don't agree with the reconsideration decision. At least $100 must be in dispute.
Department of Health and Human Services, Departmental Appeals Board (DAB) You can appeal to the DAB if you don't agree with the ALJ decision.
Federal Court Appeal You can appeal to federal court if you don't agree with the DAB decision. At least $1,000 must be in dispute. Filing an Urgent Hospital Appeal

No matter which Medicare plan you are in, you have certain protections when you're in the hospital. You can get a review right away if you are denied care or told to leave the hospital before you or your doctor think you are ready to go.

Your first step is to get your denial of care or "hospital discharge notice" in writing. The notice will tell you how to contact your state's Quality Improvement Organization (QIO).

Quality Improvement Organizations (formerly called Peer Review Organizations (PROs) are groups of practicing doctors paid by Medicare to check on and improve health care. In order to get an urgent review, you must file the appeal by noon of the first business working day after you are notified The QIO will start to review your "hospital discharge notice" as soon as it gets your request. It must make a decision no later than one business working day after the request is received.

As long as you contact the QIO by noon of the first business day after you receive the discharge notice, you won't have to pay for your hospital stay while the QIO reviews your case. You won't have to pay for these days no matter how the QIO decides.

If you don't agree with the QIO's decision, you can ask it to reconsider. The QIO must make a decision within three working days.

Appealing a Denial of Doctor Care in Original Medicare (Medicare Part B)

Denial Notice + Initial Determination (Review)
You get a notice, usually a Medicare Summary Notice (MSN), denying you care or refusing to pay for care. The notice or MSN serves as the initial review, gives you instructions on how to appeal and includes the filing deadlines

Reconsideration
You can appeal to Medicare if you don't agree with the initial determination. Ask your doctor to support your appeal by calling or writing to Medicare about your case

Fair Hearing
You can file a written request for a fair hearing if you don't agree with the reconsideration decision. At least $100 must be in dispute.

Administrative Law Judge (ALJ) Hearing
You can request a hearing with an ALJ if you don't agree with the fair hearing decision. At least $100 must be in dispute.

Department of Health and Human Services, Departmental Appeals Board (DAB)
You can appeal to the DAB if you don't agree with the ALJ decision.

Federal Court Appeal
You can appeal to federal court if you don't agree with the DAB decision. At least $1,000 must be in dispute. You have the right to a fast or urgent appeal - within 72 hours - if your life, health or full recovery might be in danger by a delay.

You can file a grievance with your plan for not providing a fast response. Send a copy of your grievance to CMS (The Centers for Medicare and Medicaid Services), the federal agency that runs Medicare. Also send a copy to your senator and member of Congress.

Applealing in Medicare + Choice Plan

Non-Urgent 

You ask your Medicare plan to provide or pay for health care.

Organizational Determination

Your plan must send you a written notice of their decision, within 14 days for a request for health care and within 30 days for a request for a payment. If your request is denied, the notice must include the reasons for the denial and instructions on how to appeal.

Reconsideration

You can ask your plan to reconsider if you don't agree with the organizational determination. This reconsideration must be done by someone outside the plan.

Center for Health Dispute and Resolution (CHDR)

If your plan still denies the service or payment in whole or in part, it must send your appeal to CHDR, an independent review group.

Administrative Law Judge (ALJ)

You can request a hearing with an ALJ if you don't agree with the CHDR decision. At least $100 must be in dispute.

Department of Health and Human Services Departmental Appeals Board (DAB)

You can appeal to the DAB if you don't agree with the ALJ decision.

Federal Court Appeal

You can appeal to federal court if you don't agree with the DAB decision. At least $1,000 must be in dispute.

Urgent

You ask your Medicare plan to provide or pay for health care and ask your plan to make a decision right away.


Organizational Determination

Your plan must give you a decision within 72 hours.

Reconsideration

You can ask your plan to reconsider if you don't agree with the organizational determination. This reconsideration must be done by someone outside the plan.

Center for Health Dispute and Resolution (CHDR)

If your plan still denies the service or payment in whole or in part, it must send your appeal to CHDR, an independent review group. CHDR must make a decision within 10 days.

Administrative Law Judge (ALJ)

You can request a hearing with an ALJ if you don't agree with the CHDR decision. At least $100 must be in dispute.

Department of Health and Human Services Departmental Appeals Board (DAB)

You can appeal to the DAB if you don't agree with the ALJ decision.

Federal Court Appeal

You can appeal to federal court if you don't agree with the DAB decision. At least $1,000 must be in dispute

AARP Resources

Understanding Medicare, Medigap, and Medicaid
AARP explains how these programs work.

Additional Resources

Your Medicare Rights and Protections
Information about your rights and protections under Medicare.

State Health Insurance Assistance Program (SHIP)
How to contact your State Health Insurance Assistance Program (SHIP), an important Medicare partner. Free one-on-one health insurance counseling to people
with Medicare.

Medicare Rights Center (MRC)
An independent source of Medicare information for consumers. Publications available for a fee include "Your Appeal Rights: Getting the Most from Medicare," and "Medicare HMOs: Your Rights and Responsibilities."

Center for Medicare Education
Read "The Medicare Appeals Process" and "Due Process in Medicare Appeals: A Primer." Both provide a detailed account of the appeal process.

Center for Medicare Advocacy
Education, publications, advocacy, and legal help.