JustCare

Tag: Appeal

  • Anthem keeps people from getting ER care simply by claiming it may not pay for it

    Anthem keeps people from getting ER care simply by claiming it may not pay for it

    The New York Times has a follow-up story on Anthem, the insurer that unconscionably denied some of its enrollees coverage for emergency care if it did not believe their diagnosis warranted it. According to a new congressional report, Anthem has reversed its policy. Still, Anthem likely has deterred its enrollees from seeking ER care.

    In 2017, Anthem denied coverage for more than 12,000 emergency room visits, stating that they were unnecessary and “avoidable.” However, the patients who appealed Anthem’s denials were successful in most cases. The benefit to Anthem is that most people do not know they can challenge an appeal and that it can be worth it to do so. So, they ended up stuck paying ER bills that they likely should not have had to pay.

    Anthem says it has now changed its policy, limiting its denials for ER visits. And, there is some evidence that it is now approving ER care in most instances. But, there is also a fear that its enrollees are worried about being denied coverage for their ER visits and not seeking ER care when they need it.

    Anthem has been sued by doctors’ groups, who allege that Anthem violated the law with its ER policy since it forced patients to determine whether they needed ER care when they did not know their diagnoses. Let’s get real. People generally do not know whether they are having a heart attack or heartburn.

    Anthem says that it is simply trying to keep its costs down since ER care is so expensive. Of course, the less it spends on care, the more profits it makes. Rather than penalizing patients who think they need ER care because ER costs are so high, Anthem should be arguing for Medicare for all, which would include rational prices for care.

    Congress, for its part, should step in and support Medicare for All. Senators and House members should recognize that commercial insurers are unable or unwilling to rein in excessive and unsustainable provider costs. Instead, they shift responsibility onto their enrollees

    If you support Medicare for all, please sign this petition.

    Here’s more from Just Care:

  • If your health plan denies payment, fight back and appeal

    If your health plan denies payment, fight back and appeal

    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.  If you have Medicare, it’s easy to appeal, it won’t cost you anything, and the odds are high that you will win, saving yourself a lot of money.

    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. Be sure to read your denial notice carefully and follow the procedures listed on the form.

    With traditional Medicare, if you are denied coverage for a doctor or other medical service, all you need to do is return the Medicare Summary Notice (MSN) 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. How to do so, depends upon the particular service you are appealing. The denial notice explains what to do. And, keep in mind that if the Medicare provider did not tell you in advance that it believed Medicare would not cover the service and have you sign a waiver agreeing to pay privately, you are not liable for the cost of care. If you did sign the waiver, you have the right to demand the provider bill Medicare. It is highly possible Medicare will cover the care, especially if you get a letter from your treating physician explaining why the care was medically necessary.

    With a Medicare Advantage plan or other private health plan, call the health 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 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.

    To appeal a Part D prescription drug denial, the Evidence of Coverage document you get from your plan explains your rights, including how to appeal. You can also call your plan. If possible get a written letter from your doctor explaining why you need the particular drug your Part D plan is denying.

    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.

    N.B. Even with commercial 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. “

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  • Medicare covers array of medical equipment and supplies

    Medicare covers array of medical equipment and supplies

    In addition to covering medical and hospital services, Medicare covers an array of medical equipment and supplies. In order for Medicare to pay for medical equipment, you must need to use it inside your home and it must be able to be used repeatedly. You must also follow Medicare’s coverage rules.

    In brief, Medicare covers durable medical equipment so long as you need it to help you in your home with your health condition. It could be a wheelchair, a walker, a crutch, a power scooter, a hospital bed, home oxygen equipment, a diabetes self-testing equipment, a seat lift or a nebulizer. If it assists you in your home, you can also use it outside your home. But, even if you need it at home, if it is not medical in nature, such as an air conditioner, Medicare will not cover it.

    Medicare also covers disposable supplies that are needed to use the durable medical equipment, including diabetes test strips used with diabetes self-testing equipment, drugs used with nebulizers and lancets.

    In order to qualify for Medicare coverage,

    • your doctor must certify that you need the equipment.
    • the equipment must come from a Medicare-approved medical equipment supplier.
    • you must buy certain equipment, but you can rent most equipment.
    • you generally must get basic equipment; you usually must pay for any upgrades, unless they are medically necessary.

    If the equipment needs to be repaired, Medicare may help cover the cost. If the item is damaged and cannot be repaired, lost or stolen, Medicare will generally replace the equipment. Medicare will also replace equipment that has outlived its useful lifetime and cannot be repaired.

    And, if for any reason, Medicare denies coverage, you can appeal. You can send the denial notice back to Medicare, along with a letter from your doctor explaining your need for the equipment, and ask Medicare to review its decision. You have a high likelihood of winning the appeal.

    Here’s more from Just Care:

  • Health plans must cover preventive care services in full

    Health plans must cover preventive care services in full

    It’s always wise to question your health plan if it denies coverage for your care or covers less than you expected. Improper denials or inadequate coverage appear all too common. The latest evidence comes after a report by the National Woman’s Law Center finding that health plans had been refusing to cover all types of women’s contraceptives in full in violation of the Affordable Care Act. Last week, the Department of Health and Human Services made clear that health plans must cover preventive care services in full.

    Health plans cannot pick and choose among the preventive care contraceptive services they cover. They must cover the full range of FDA-approved contraceptive services. They must also cover well-woman visits at no charge to the patient.

    The National Woman’s Law Center surveyed 100 insurance companies in seven states and found that 15 health plans failed to cover all forms of FDA-approved birth control, including Cigna, Aetna and Anthem Blue Cross Blue Shield. The Kaiser Family Foundation conducted a similar study of 20 insurers in five states and found, among other things, that some insurers do not cover birth control patches, four insurers did not cover the contraceptive implant Implanon, and one insurer did not cover the NuvaRing.

    The Department of Health and Human Services clarified that the health plans must offer for free at least one of the 18 contraceptive drugs available, but they can cover the generic drug in full and charge a copay for the brand name drug. The ruling will take effect in January 2016.

    For answers to a range of questions on the Affordable Care Act, visit the Center for Consumer Information and Insurance Oversight. And, remember, if your health plan denies coverage, fight back.  Here’s how.