What To Do When Medicare Denies a Service?

I get the question about twice a week from a client or potential client about what can they do if they have been denied access to a test, surgery, or some other procedure. The answer is fairly simple, either file an appeal or grievance to have the decision reviewed.

Now at this point I have to differentiate between a Medicare or Medicare Advantage denial. If you only had Medicare Part A and B and Medicare denied you then you would have to appeal to Medicare. Medicare by itself or with a Supplement rarely denies a procedure unless it experimental or in a trial phase. Medicare will also deny procedures that are cosmetic, not medically necessary. Also, procedures like Acupuncture are denied. The nice thing about a Supplement is they are basically along for the ride to pay whatever Medicare does not pay as long as it is a Medicare approved procedure.

Medicare Advantage plans are a horse of a different color. Medicare Advantage plans can be an Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), or Private Fee For Service (PFFS). But the one thing they have in common is they all have a network of Physicians or Facilities they would like for you to use.

The most restrictive of the Medicare Advantage plan is the HMO. Every referral has to be written by your Primary Care Physician (PCP). Every referral to another Physician, every referral for an x-ray or MRI, every referral for surgery has to be approved by the Insurance Company. PPO plans are usually more liberal allowing you to see a specialist without a referral, but once again the Insurance Company can deny payment.

What are your options if you are denied a service? Well they are different for each plan, Original Medicare and Medicare Advantage. I have several easy to use links that take you directly to Medicare. (Click Here)

First let’s talk about Medicare. If you are going to appeal Medicare there is a page at Medicare.gov that will walk you through the steps. The most important thing to remember is that you will need documentation from your Clinicians as to why you need the particular procedure being prescribed. the way Medicare and most Insurance Companies view things when they deny them is that there is possibly a more cost effective alternative to what your Clinician is recommending. Many people are able to win an appeal by having all the necessary documentation as to why that particular procedure is needed.

Medicare Advantage plans are run by Private Insurance Companies. We all know at the end of the day these companies are in business to make money. Many of the clients I work with have had their bad experiences with a Medicare Advantage Company. It is not that the Insurance Company wants to hurt the client by denying service, but they often want to be assured that the test or procedure is Medically Necessary and there is not a more cost effective alternative. The frustrating part here will be the wait for your Clinician to submit documentation and the Company turn around time to approve it which may take weeks. I would love to be able to give you links for the appeal with the Insurance Companies, but there are just to many. I believe at the current time there are approximately 2200 different Medicare Advantage plans in the United States, down from 2800 plans just two years ago.

The other thing to remember is even if your Private Insurance Medicare Advantage still does not approve you, you have the ability to appeal to Center for Medicare and Medicaid services (CMS) which is Medicare itself to have them make a determination to override the Insurance Company.

Lastly, the same hold true for your Part D Prescription Drug plans. If the insurance company denies a medication you can appeal it with proper documentation. Part D is an article by itself because of the intricacies involved with formularies, out of pocket cost, deductibles, and preferred pharmacies.

If you want more information stop by my site National Senior Savings (click here) where we have a multitude of free resources available for you under education and also our blog section.

Just remember, when you get a denial of service, don’t panic, follow the appeal process and you will likely get a decision in your favor.