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Understanding Medicare Denials and How to Appeal Them

April 25, 2017

Understanding Medicare DenialsMedicare is notorious for having stringent guidelines for reimbursement, so it’s no surprise that 10 percent of claims were denied in an any given year. However, just because a claim is denied does not mean you have to accept the results. Appealing a Medicare claim might be a bit of a hassle, but it’s generally successful, with a 40 percent success rate for Part A and a 53 percent success rate for Part B in average last few years. 

Reasons to Appeal

There are many different instances in which you are eligible to file an appeal. For example, you may have been denied coverage for:

  • Prescriptions, health care services, or supplies which you have already received or used
  • Prescriptions, health care services, or supplies which your doctor has requested for you
  • More expensive drugs that your doctor deems are medically necessary to treat your condition

While Part A covers inpatient services and Part B covers outpatient services, the appeals process for both of these plans is identical. You’ll be able to begin appealing once you receive the Medicare Summary Notice that provides more details about your claim denial.

Request for Re-determination

The first level of appeal is easy enough, as all you have to do is file an appeal to the Medicare contractor that reviewed your claim. There’s no minimum claim amount involved, and you will have 120 days to file an appeal after receiving your Medicare Summary Notice. The contractor will review the patient’s medical history and make a decision based on that. 

Request for Re-consideration

If this appeal does not go well, you can elevate it to a level 2 appeal. This involves having a Qualified Independent Contractor (QIC) conduct a new review of your original claim to see if it meets Medicare’s guidelines. Again, there is no minimum claim amount, and you will have 180 days to file an appeal after receiving the results of your Redetermination.

Related Article: Four Simple Steps to Reduce Medical Claim Denials

Administrative Law Judge Appeal

After being denied in the Reconsideration step, the next level of appeal is an Administrative Law Judge hearing with the Office of Medicare Hearings and Appeals. While this sounds serious, it does not require you to hire a lawyer, as it is an informal proceeding. Most cases are handled over the phone or via video conference, as there are only four field offices in the country. In this stage, the minimum claim amount is $160, and you will have 60 days to file an appeal after receiving the results of your Reconsideration.

Medicare Appeals Council

If the court was not on your side, the fourth level of Medicare appeal is to bring your case before the Medicare Appeals Council. This review will be conducted separately from your previous reviews and might require you to seek legal assistance to ensure you’ve built a solid case. The minimum claim amount is once again $160, and you must file an appeal 60 days after receiving the results of your Administrative Law Judge hearing. 

Federal District Court

Finally, if all the previous levels of appeals have failed you, the last and final chance to get compensation is by filing a federal district court civil lawsuit. Because this is a formal court appearance, you will need to hire legal representation to assist you during the case. However, to escalate things to this level, the minimum claim amount must be at least $1560, and you have to file it within 60 days of receiving your Medicare Appeals Council results. 

Still not sure if you know how to handle your Medicare denials? If you’d like some extra help, M-Scribe can provide answers to your questions and help you with the appeal process. Simply call me at 770-666-0470 or email to get started today.


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