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The “Appealing” Part of Medicare Part (A)

By Scott B. Elkind, Esq.

As you are acutely aware, most insurer’s actively engage in “cost containment policies,” i.e., ways of preventing payment of benefits to increase profits.. So, if such practices are good for the bottom line of industry, why shouldn’t the government do the same. This is one of the guiding principles underlying Medicare denials. In addition, medicare providers are placed in the tenuous position that they must pay the cost of care should they erroneously inform a beneficiary that care will be covered. So, it remains in their best economic interest to erroneously deny coverage as there is no penalty for wrongful benefit denials.

Despite the volume of erroneous claims denials there are definite instances when denial is proper. Examples include claims for care which is specifically excluded from coverage or is not medically necessary under the circumstances. Unfortunately, it is the “medically necessary” denials which often deserve close examination and, in many cases, pursuit of appeal. This subject will be covered in a subsequent article.

The inconvenient aspect in this process is the notification process. Notification by the provider is given to the beneficiary. Unfortunately, this may not be the most dependable person to receive a legal notice of such import. Further, the first provider denial notice received by the beneficiary may not be an operative document for the purpose of creating the right to appeal. Not until the beneficiary receives an “initial determination” notice from the appropriate peer review organization (PRO), intermediary, or carrier can an appeal be requested. Although, in some infrequent cases, there may be a granting of coverage where the provider original had declined (you won’t see this often).

Once an initial determination denial is received, the beneficiary must file a request for reconsideration with the intermediary within 60 days. Late filing is allowed only where good cause is shown for such reasons as illness, inability to understand, incorrect information on the notice, among others. If the reconsideration is denied or is otherwise unsatisfactory and at least $100 remains in controversy, the beneficiary can request a hearing before an administrative law judge within 60 days of receipt of the denial. This request is made directly to the Social Security Administration. If the hearing request is denied or is otherwise unsatisfactory, a beneficiary may request a review from the Departmental Appeals Board.. If over one thousand ($1,000) dollars remains in controversy following a hearing, the case may proceed into the United States District Court. Again, the same 60 day filing deadline is applicable for either route of appeal chosen.

This same Part A appeals process also applies to all home health or skilled nursing facility services appeals, whether the initial coverage for these services was sought under Part A or Part B. These appeals are filed directly with the Peer Review Organization (PRO).

Since this is the “hospital” edition, the hospital treatment exception should be explained. When a beneficiary is receiving inpatient care from a hospital and is denied coverage, an immediate review must be requested to avoid incurring hospital charges until an initial determination is received.

Please be aware that it takes many months during these periods of review and the hearing scheduling/decision process during which no update information concerning the claim is given. This often leads to frustration for beneficiaries, many of which will simply give up rather than continue to appeal.

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