If Medicare
Says No ...
Try, Try, Try Again
By
Kelly Greene
The
Wall Street Journal, March 16, 2003
Medicare, the
federal health-insurance program for the elderly and disabled, has a
built-in appeals process to help if your claim gets turned down -- and your
chances of success are better than you might imagine.
In fact, more than
60% of the people who appeal eventually win, according to research by the
Center for Medicare Education, a project of the American Association of
Homes and Services for the Aging in Washington.
Often, the point
of contention is whether Medicare considers your treatment to be
"medically necessary," meaning it's needed for the diagnosis or
care of your condition, is good medical practice where you live, and isn't
mainly for the convenience of you or your doctor.
But sometimes a
rejection of payment results from something as simple as a coding error in
your doctor's office. In either case, piping up often persuades Medicare to
see things your way, according to the Medicare Rights Center, a New York
advocacy group that helps people file appeals (www.medicarerights.org
or 800-333-4114, ext. 1).
You can get more
information and appeal forms on Medicare's site www.medicare.gov/Publications/Pubs/NonPdf/appeals.asp,
or by calling 800-633-4227.
You can also get
help from your state's health-insurance counseling program, which you'll
find listed at the www.medicare.gov/Contacts/Related/Ships.asp
Web site.
If you decide to
file an appeal, here are some tips: When you get the "Medicare Summary
Notice" that outlines your denial, write "Please Review" on
the bottom, sign the back and send the original to the address on the form
-- by certified mail. Include a letter that says why Medicare should cover
the claim.
When possible, get
your doctor, or other medical provider, to write a letter of support. Save
copies of all the paperwork.
Most important,
file your appeal quickly: Your deadline is usually 120 days from the date on
the denial. (The deadlines sometimes come quicker if you're in the hospital
or trying to get a service approved through a health-maintenance
organization.)
Bob Gill, who is
disabled with muscular dystrophy in St. Helena, Calif., spent 17 months
tussling with a Medicare HMO over its denial of a power wheelchair that his
doctor thought would alleviate some pain. He worked with the Medicare Rights
Center to file an appeal -- and won. He recommends writing everything down.
"Chronicle all the little conversations, when you had it and with
whom," he says. "I had a 16-page miniseries."
* * *
By mid-April,
Medicare plans to make it a little easier to shop for home-health services.
Last year, the
agency posted nursing-home data on the Web, showing how individual locations
around the country compare with others in their region. The site (www.medicare.gov/NHCompare/Home.asp)
uses indicators such as what percentage of patients have bedsores or have
lost the ability to perform basic daily tasks.
Now, the
government is gearing up to provide information about individual
home-health-care providers as well. Next month, Medicare plans to release
information for eight states -- Florida, Massachusetts, Missouri, New
Mexico, Oregon, South Carolina, Wisconsin and West Virginia -- then expand
it to all states by the fall, according to a spokeswoman for the Centers for
Medicare and Medicaid Services.
The home-health
site won't include complaint information, as the nursing-home site does, but
it should list each provider's performance in 11 quality measures, ranging
from improvement in getting around to meeting basic daily needs and
improvement in mental health.
In addition to
being a consumer tool, there are hopes that such data can help the
long-term-care industry improve its track record.
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2002 Global Action on Aging
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