Millions of Americans rely on Medicare for health care coverage and payment for essential medical services. However, Medicare claims are often denied for several different reasons. This can put someone in a financial bind and leave them wondering how they will pay for their medical bills or prescription drugs.
So, do you have any options if you receive a Medicare denial of your claim? Yes! You can appeal Medicare’s decision at several levels – even to federal court! We will explain everything you should know about the Medicare appeals process and give you some great tips for winning your appeal.
Overview Of Medicare Appeals Process
If you disagree with Medicare’s decision on providing coverage or payment for a specific medical service, you have certain appeal rights. You can make an appeal request for Medicare to reconsider their decision. There are five levels to the appeals process, although they may not all be necessary for your specific appeal. The five levels will be discussed in more detail in the next section, but here are more specifics about the decisions that may be appealed.
Denial of Coverage / Partial Coverage
If Medicare denies your request to cover a particular medical service, supply, item, or prescription drug you believe they should cover, you can appeal that decision. Likewise, that decision can be appealed if they deny payment for a service or medical item you have already received. You might also request that they change the amount you must pay for a service or drug, and you can appeal that decision if your request is denied.
Discontinued Coverage
Finally, you can appeal if Medicare stops providing payment for a service, supply, item, or drug you believe you still need. The type of plan that you are enrolled in determines which level of the appeals process you need to start with. This will also determine who hears the appeal and makes the decision. If your initial appeal fails, you may choose to appeal to the next level and continue until you reach Federal District court.
KEY TAKEAWAYS
- Filing a Medicare appeal is wise if you receive a denial notice or stoppage of Medicare coverage. Data shows that the claimant won roughly 80% to 90% of appeals.
- There are five levels to the Medicare appeals process; if your appeal is denied at one level, you can appeal to the next level.
- The appeals process can be lengthy if you proceed through all five steps. It can take over a year to receive a final ruling. However, most appeals are won in steps 1 or 2, which can take less than six months, depending on how quickly you file.
Five Levels Of Medicare Appeals
Similar to the court system, there are different levels of appeals in Medicare. You can appeal to the next level if you are unsuccessful at one level. If you go to the top, you could end up in Federal court. In practice, though, very few appeals have made it that far. Here are the different levels and what you need to know about each.
1) Redetermination
Level 1 of the appeals process is the simple redetermination request. This means that you are asking your health plan’s administrator to decide whether the service or item in dispute should have been covered when you disagree with the initial determination. In some cases, you might be asking them to make a new determination of how much Medicare should pay. Your health care plan provider is where this request goes.
For instance, if you have Medicare Part A or Medicare Part B, then your request will typically go to a Medicare administrative contractor (MAC). The provider will handle the redetermination request if you have a Medicare Advantage Plan. This is generally the easiest and most common appeal, and you can use a simple redetermination request form. This is sometimes called a Medicare Appeals Form. Remember that almost all levels of appeal require a written request.
2) Reconsideration
The next step is the reconsideration request. What happens here is that an independent entity will review the records in your case independently of the original determination. This review is performed by a qualified independent contractor (QIC) for Medicare Parts A & B. For Parts C or D, the review is done by an independent review entity.
You will want to explain why you disagree with the redetermination decision clearly, and you will need to include all the evidence that you need. This typically includes all the records from your healthcare provider and any communication with your health insurance company. Introducing new evidence or additional information at a higher level of appeal is usually not allowed unless you can show good cause why the evidence should be allowed.
At this stage, a panel of physicians might review evidence to help the independent contractors decide on the medical necessity of a service or procedure.
3) Office Of Medicare Hearings And Appeals
The third level of appeals goes to the same entity regardless of your plan type. Whether you have original Medicare, a Medicare Advantage Plan (Part C), or a Medicare Part D prescription drug plan, then your subsequent appeal would go to OMHA. This step in the process lets you explain your reasoning to an administrative law judge (ALJ). This ALJ hearing generally takes place over the phone.
If you feel an in-person hearing is warranted, you must show good cause to request it. After the reconsideration phase, a minimum dollar amount must still be disputed before requesting an ALJ hearing. The ALJ adjudicator will decide the case and issue a disposition or ruling. The time frame typically takes about 90 days for the disposition after the judge has heard the case.
4) Medicare Appeals Council
If you disagree with the ruling of the previous step, you can file an appeal with the Medicare Appeals Council. Again, this is the next step, regardless of your Medicare plan type. This council is part of the Department of Health and Human Services (HHS) Appeals Board. The council will generally decide the coverage determination within 90 days of the appeals request.
Unlike the previous step, no minimum dollar amount is required to request an appeal at this level. The council might agree with the ALJ decision or reverse or remand it. The commission has broad discretion in its decision and how the case proceeds from here.
5) Federal Court
The final appeal level is the Federal District Court. If you disagree with the council’s decision, then you can petition the court to hear your appeal. A minimum dollar amount is again required at this stage. This appeal must be filed within 60 days of receipt of the council’s decision.
Failure to strictly follow all the Federal court rules will almost always result in a denial of your petition and dismissal of your appeal. Appeals from all Medicare plans, even prescription drug coverage, could go to a Federal court judicial review.
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How Long Do You Have To File An Appeal?
The answer depends on which stage of the process you are currently in. Initially, it would help to look at your Medicare Summary Notice (MSN) for the claim you wish to appeal. A date will be printed indicating when you must file your first-level appeal.
Redetermination:
Generally, this date is 120 days from the date you received the initial determination.
Reconsideration:
When appealing your Medicare coverage decision to the second level, you must file your appeal within 180 days of the redetermination notice receipt date. So, you have about six months to file from the date the Level 1 appeal is decided.
OMHA:
From here, the timeframes for Medicare beneficiaries to appeal start tightening. You only have 60 days from the reconsideration decision letter to appeal to the OMHA.
MAC:
Similarly, you have only 60 days from the date of your OMHA decision or dismissal letter to file a MAC appeal. Failure to meet these deadlines could result in your appeal being lost.
Federal Court:
Finally, you must file your judicial review request with the Federal court no later than 60 days from the council’s decision. Deadlines in Federal court are taken extremely seriously, and failure to file on time will likely bar you from hearing your appeal.
TIP
Hiring an attorney to assist with your appeal can provide comfort in knowing you have someone with experience on your side. However, suppose you are unable to afford an attorney. In that case, nothing prevents you from representing yourselves during the process.
Tips For Winning Your Appeal
We know that you want to win your appeal, or you will not be filing it in the first place. There are some things that you should keep in mind when filing appeals with the Centers for Medicare & Medicaid Services. If you keep these tips in mind, it can significantly increase your odds of being successful.
- File Before Deadlines: The first, and maybe one of the most essential rules, is always meeting the deadlines. Failure to meet a deadline to file your appeal will almost always be grounds for dismissing your appeal.
- Use Proper Forms: Next, ensure you use the proper forms when necessary and always present your evidence clearly and concisely.
- Demonstrate Good Cause: If new evidence has become available since your last level of appeal, then make sure that you show good cause why the evidence should be allowed in your subsequent appeal. Use data and facts to present your case, and try to refrain from stating your opinion unless specifically asked by the judge.
- Hire an Attorney: Finally, consider hiring an attorney if you feel you cannot adequately navigate the appeals process independently. Having an attorney or representative familiar with the rules and the process can be a huge advantage. They will know the filing deadlines as well as the evidence that will be required to win your appeal. Many attorneys will even offer you a consultation at no charge so they can give you a rough idea of your odds of success should you decide to proceed with an appeal.
The Bottom Line
If you disagree with Medicare’s decision on whether to cover a service or how much to pay, then you have a right to file an appeal. It could be nearly any decision, from whether to pay for care in a skilled nursing facility to whether a prescription drug is medically necessary.
There are five levels of appeal, with the final level going to the Federal court. Few appeals make it that far. You can take steps to increase your odds of winning, such as meeting all the deadlines, having your evidence in order, and even hiring an attorney to represent you.
If you feel that your Medicare claim has been improperly denied, then file the first level of appeal to get the process started.
Frequently Asked Questions
Medicare appeals are pretty successful. Data has shown that roughly 80% to 90% of appeals are won by the claimant who is appealing the decision.
Do not give up if you do not win your appeal at the first or second level. Keep going as far in the appeals process as possible to increase your odds of winning your appeal.
It depends on which stage of the appeals process you are on.
- Level 1’s general timeframe to respond to the appeal is 60 days.
- At level 2, the decision is again made within 60 days. If a decision cannot be reached in this timeframe, you will still receive notice of your rights in the appeals process.
- For level 3, OMHA has 90 days to decide after the appeal has been heard.
- For level 4, the timeframe depends on how the case arrived, but it is generally 90 to 180 days.
- Finally, a level 5 appeal has no time limit. This means that the Federal Court can take as long as necessary to decide the disposition of the appeal.
The benefits of pursuing an appeal are pretty obvious. First, if you win the appeal, Medicare will cover the item or service initially denied. This means that Medicare will pay for that health care service instead of you paying for it.
In some cases, you might have already paid for the service. This means that Medicare will reimburse you for the payment that you have already made. Having Medicare pay for items they should pay for will save you money and allow you to receive the treatments you genuinely need.
At most levels of the appeal, the reviewing party will look at the evidence in the record. This means that they might review your medical records or medical history along with the contract terms of your health care plan.
In some cases, they might ask a panel of physicians to review the evidence and decide regarding the medical necessity of an item or service. This is why it is imperative to include as much evidence as possible at the first level of your appeal. It can be challenging to introduce new evidence later in the appeals process.
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