Tuesday, June 17, 2008

How to win a Medicare/HMO appeal!

These days, almost every senior has experienced denial of Medicare payment for a legitimate health service by an HMO or other insurer—but you don’t have to passively accept the denial. I didn’t. It was time consuming but persistence usually paid off in reversals of these denials.

When my mother was enrolled in one of those so-called comprehensive health plans for seniors, it seemed as though every doctor she saw and every procedure or treatment provided produced an immediate letter of rejection.

As a result, I had a chance to hone my skills at appealing these actions. I believe that the appeals process may deliberately use cumbersome and bureaucratic procedures with intent to discourage appeals. Faced with this hassle, many folks just give up in disgust and pay the bills out of pocket. This is unfortunate.

My take is that you can get many of these rejections reversed with persistence and a little bit of knowledge. As just one example, how many of you know the following Medicare rule?

The HMO/CMP Manual #2116 states that it is the Health Plan's responsibility to ensure that physicians or providers know whether services are covered by Medicare or by the Plan as an additional or supplemental benefit and that they properly use the authorization system. If the Medicare beneficiary receives services under the direction or authorization of a plan physician and the beneficiary has not been informed that he or she is liable for the costs of such services, then the Health Plan must pay for such services."

This rule can be one of the most important arrows in your quiver. In most cases, a physician orders the medical service being denied without specifically informing the patient (or representative payee) that he or she might have to pay for the service. If they don’t tell you, you don’t have to pay!

This is especially true in senior housing settings where patients may not have the cognitive awareness to understand complex Medicare and insurance rules anyway.

Another truism is that organizations such as health insurers must follow their own procedures to prevail. If they fail to do so for any reason it significantly weakens their case. The good news is that they are often victims of their own complexity and, if you watch carefully, you may catch them diverging from their own procedures. Document this and call them on their failures. Examples of successful letters I have used are available on request. Try it! You’ll be pleased at the results.

2 comments:

ldagosta said...

How would you approach this scenario: HMO denies claim for breast reduction, based on this: they only provide the service to people who are diagnosed with breast cancer. this patient does not have breast cancer, but her health is in jeopardy as a result of her inability to function due to mass of weight limiting her mobility. Presently suffer from back problems, breathing problems. severe depression, excessive weight gain heart ailments all over the course of a year due to severe weight in her breasts. HMO denied claim for reduction. She will appeal but based on what she does not have breast cancer.

Bob Tell said...

This is a tough situation and it sounds like the patient is on the right track pursuing an appeal. I recommend that she should try to get her doctor's help in convincing the HMO that the issue is medical and not cosmetic. It's a long shot but worth a try. Good luck with her appeal.