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What To Do When Medicare Says 'No'

Your doctor suggested you have a minor operation or procedure, you went ahead and had it done, and now Medicare won't pay for it. What should you do? Appeal.

Medicare covers procedures that are deemed medically necessary. "Appealing is easy and most people win so it is worth your while to challenge a Medicare denial," says the Medicare Rights Center, a national nonprofit organization. The denial of coverage may be due, for example, to a simple coding error in your doctor's office.

People have a strong chance of winning their Medicare appeal. According to Center, 80 percent of Medicare Part A appeals and 92 percent of Part B appeals turn out in favor of the person appealing.

The Medicare Rights Center offers the following tips to maximize your success when appealing your denial:

  • Write "Please Review" on the bottom of your Medicare Summary Notice (MSN), sign the back and send the original to the address listed on your MSN by certified mail or with delivery confirmation.
  • Include a letter explaining why the claim should be covered.
  • When possible, get a letter of support from your doctor or other health care provider explaining why the service was "medically necessary."
  • Save photocopies and records of all communications, whether written or oral, with Medicare concerning your denial.
  • Keep in mind that you only have up to 120 days from the date on the MSN to submit an appeal.

The Center notes that the appeals process is slightly different if you are in a private Medicare plan, like an HMO or a PPO. One difference is that you have only 60 days from the date on the denial notice to file an appeal.

Resources:

For information on how to fight a hospital discharge, click here.

For more on the Medicare Rights Center, visit its Web site at http://www.medicarerights.org

To download Medicare appeal forms from the government's Medicare website, click here.