Health insurance Medicare Your Coverage Options

If your health plan denies payment, fight back and appeal

Written by Diane Archer

It likely won’t be your first reaction, but when your health plan denies payment, fight back and appeal.  You should absolutely challenge that denial.  It will take a bit of your time, but it won’t cost you anything and the odds are high that you will win, saving yourself a lot of money.  Be sure to read your denial notice carefully and follow the procedures listed on the form.

One of the best-kept Medicare secrets is that the vast majority of people who challenge a Medicare denial win.  But, almost no one makes the challenge and appeals.

With traditional Medicare, all you need to do is return the Medicare Summary Notice form to Medicare, circle the denial and fill out the section at the bottom of the MSN for the Medicare insurance carrier to review the denial.  It’s that easy.  Even if the doctor made you sign an Advance Beneficiary Notice that Medicare will not cover the service, you should appeal.  The doctor could be wrong, especially if the doctor says that the service is medically necessary.

If Medicare is denying a hospital service, a home care service, hospice care or a service from a skilled nursing facility, you should also appeal.  For information on how to do so, visit Medicare Interactive.

Even with private health plans, according to a report from the General Accountability Office, “coverage denials, if appealed, were frequently reversed in the consumer’s favor. . . . [D]ata from four of the six states on the outcomes of appeals filed with insurers indicated that 39 percent to 59 percent of appeals resulted in the insurer reversing its original coverage denial. “

With a Medicare Advantage plan or other private health plan, call the plan and ask the insurer to explain why you were denied coverage. You will likely need to speak to the doctor about the coverage denial.  It could be that the doctor coded the procedure incorrectly or did not comply with health plan rules and that the doctor should be responsible for the cost.

If you are not able to resolve the matter, file an appeal with your insurer.  You will likely need a formal written notice of denial to do so.  It is often helpful to have a letter from your doctor explaining the need for your care.  So long as the care is medically necessary, your insurer should cover it.

There are several appeal levels, so even if you don’t win at the first level, appeal again.  If you have Medicare and need help, contact your state health insurance assistance program (SHIP) for free assistance. You can get the number for your SHIP here.  

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