Medicare Appeals: What To Do When You Are Denied Care under Medicare

Medicare reliably covers a wide range of medical services but a lot of people experience times when Medicare or a provider tells them that a service is not covered. These determinations are not always correct, and there are steps (e.g., Appeal Rights) one can take to have these determinations reviewed and often-times revised. Curious to learn more? Join representatives from Arlington's State Health Insurance and Assistance Program (SHIP) to learn about Medicare Coverage and Appeals. Within their presentation, representatives will discuss Medicare Basic Appeals, help understanding Medicare benefits and options, how to take the first steps in filing an appeal, and finding help in the process.  

For questions MedicareHelp@arlingtonva.us

Questions Asked

• Does VICAP help people chose Medicate supplemental plans?
• Is it required that the notices are able to be read and understood by the patient?   I had an experience where the letter was dropped off in the room, not discussed with patient and on a paper barely readable.
• What are considered valid arguments to extend a hospital admission?  Can absence of a safe discharge plan be enough to justify extension of coverage?
• If the patient is not physically or mentally able to file a form who can file for them?
• Please reinforce the importance of knowing whether a patient is admitted or "on observation" (outpatient) when it comes to paying for service).
• Do you need an Appt of Representation form if you have a Medical POA form already in place?
• When sending an appeal to an IRE for a denied MRI, is there representtion available or needed from VICAP on that appeal?

Chat Transcript

12:05:08     From Steve Gurney - ProAging Community : You can connect with Michelle and Charlie at MedicareHelp@arlingtonva.us

12:05:53     From Steve Gurney - ProAging Community : The Virginia Insurance Counseling and Assistance Program (VICAP) is part of a national network of programs that offers FREE, unbiased, confidential counseling and assistance for people with Medicare. https://www.vda.virginia.gov/vicap.htm

12:07:03     From Rebecca Finegan : are you in VA area only?

12:07:48     From Rebecca Finegan : thank you

12:08:48     From Michelle Thomas : Find your local SHIP - https://www.shiphelp.org/

12:10:28     From Michelle Thomas : There are 54 SHIP grantees (one in all 50 states, Puerto Rico, Guam, the District of Columbia, and the U.S. Virgin Islands)

12:12:52     From Gregory Rehkopf : Have not experienced a Medicare denial.

12:13:32     From mary busse  to  Hosts and panelists : When you are admitted to the hospital, you are given a document that says you are entitled to challenge a decision.  what is the process? I was very anxious and hospital staff told me I didn't have to go home.  I didn't know what would happen if they decided not to pay. I have to leave for a little bit, but wanted to be sure to get my question in.

12:14:08     From Michelle Thomas : Hi Gregory - thank you!

12:14:27     From Michelle Thomas : Hi Mary - your question will be addressed within this presentation. Thank you.

12:17:06     From Steve Gurney - ProAging Community : Today's discussion is done in partnership with VHC Health, you can learn more about the Senior Health Program at https://www.vhchealth.org/classes-events/healthy-aging/ access their Resource Guide at https://www.vhcsrg.com/

12:23:22     From Steve Gurney - ProAging Community : BFCC-QIO “Beneficiary and Family Centered Care Quality Improvement Organization”                               Livanta- www.livantaqio.cms.gov

KEPRO  - www.keproqio.com

12:23:56     From Morris Klein : 1. Please clarify who is responsible to pay for services during the time of appeal.                             2.  It is my experience that even if you win an appeal from a denial of Medicare for an SNF, the facility turns around an almost immediately issues a new termination notice

12:24:40     From mary busse  to  Hosts and panelists : My question really is what would have happened had I refused to go home. If coverage was denied...would I have to pay if not covered.

12:24:51     From Cheryl Johnson  to  Hosts and panelists : Hello this is CherylJohnson and my question is will this session be available for replay via email…thank you

12:26:12     From Michelle Thomas  to  mary busse and all panelists : Hi Mary thanks for your inquiry. This is something that is being addressed within the presentation.

12:26:27     From Steve Gurney - ProAging Community  to  Cheryl Johnson and all panelists : Hi Cheryl - yes it is recorded and will be at https://www.retirementlivingsourcebook.com/videos?q=proaging later this afternoon!

12:26:57     From Michelle Thomas  to  Morris Klein and all panelists : Hi Morris Klein - thanks for your inquiry. This is something that is being addressed within the presentation.

12:31:47     From Michelle Thomas : Learn more about the QIO Program here: https://www.cms.gov/medicare/quality/quality-improvement-organizations

12:32:05     From Ann Sloane  to  Hosts and panelists : My question is in the Q&A

12:33:43     From Pamela Mills : exactly!  or have cognitive impairment.

12:34:31     From Connie Freeman  to  Hosts and panelists : The hospital sent mom to a Nursing  Center. My niece was in the ambulance and signed the admittance form and is now getting $6,000 bills. They claim not to provide financial assistance. She has Kaiser under Medicare Advantage.

12:36:18     From Michelle Thomas  to  Connie Freeman and all panelists : Hi Connie! It's wonderful to see you in the virtual room. We will do our best to provide a high level overview of your question live but an individual counseling session may work best. Would you please email us at MedicareHelp@arlingtonva.us? We would be happy to talk with you offline. Thanks!

12:38:40     From Kimberly Hughes : How difficult is it to get out of a Medicare Advantage plan when you realize that your needs are not covered and you have received denial for services rendered.

12:40:01     From Michelle Thomas : The Medicare Advantage Open Enrollment Period runs from January 1 – March 31 each year. It allows you, if you're already enrolled in a Medicare Advantage plan, to switch to another Medicare Advantage plan or disenroll and return to Original Medicare.

12:41:04     From Michelle Thomas : One may also be eligible to change their plan if a special enrollment period applies - https://www.medicare.gov/basics/get-started-with-medicare/get-more-coverage/joining-a-plan/special-enrollment-periods

12:45:17     From Steve Gurney - ProAging Community : Call your State Health Insurance Assistance Program (SHIP) for counseling around appeals or your care ending. Visit www.shiphelp.org or call 877-839-2675

12:45:40     From Steve Gurney - ProAging Community : DC

202-727-8370

https://dcoa.dc.gov/service/dc-state-health-insurance-assistance-program-ship

MD

800-243-3425

https://aging.maryland.gov/Pages/state-health-insurance-program.aspx

VA

800-552-3402

www.vda.virginia.gov/vicap.htm

12:46:53     From Steve Gurney - ProAging Community : Eldercare Locator - 800-677-1116 or https://eldercare.acl.gov 

Medicare - www.medicare.gov/claims-appeals

Medicare Rights Center- www.medicarerights.org & www.medicareinteractive.org 

State Health Insurance and Assistance Program - www.shiphelp.org 

The Center for Medicare Advocacy - “Home Health Care Toolkit” - www.medicareadvocacy.org

12:46:58     From Michelle Thomas : 2024 Medicare & You handbook - https://www.medicare.gov/publications/10050-Medicare-and-You.pdf

12:47:26     From Steve Gurney - ProAging Community : Medicare & You - The "Medicare & You" handbook is your official guide to Medicare. We mail an updated printed handbook to all Medicare households in late September. You can also download a copy anytime, or access it electronically for the most updated information available.  https://www.medicare.gov/medicare-and-you

12:48:36     From Gelareh Bassiry : I feel like you need a law degree to understand all of this complicated processes

12:49:24     From Michelle Thomas : Hi Gelareh! Thank you for joining us today. SHIP Counselors are here to help!

12:54:52     From Michelle Thomas : Information on Medicare and Observation status - https://www.medicareinteractive.org/get-answers/medicare-covered-services/outpatient-hospital-services/medicare-and-observation-services

12:55:49     From Michelle Thomas : Observation patients are billed as an outpatient service (under Medicare Part B). Inpatient admissions are billed under inpatient services (under Medicare Part A). Observation patients may have insurance co-pays and deductibles associated with the outpatient terms of their health insurance policy.

12:57:08     From Ann Sloane  to  Hosts and panelists : If someone is switched from observation to inpatient on day 2, then when what days count towards the 3-day rule?

12:58:01     From Steve Gurney - ProAging Community : Craig Thomson 12:54 PM 

When sending an appeal to an IRE for a denied MRI, is there representtion available or needed from VICAP on that appeal?

12:58:15     From Michelle Thomas  to  Hosts and panelists : The 3-day rule requires the patient to have a medically necessary 3-consecutive-day inpatient hospital stay, which doesn't include the discharge day or pre-admission time in the emergency department (ED) or outpatient observation.

13:07:45     From Steve Gurney - ProAging Community : The Medicare Appeals Process: A Comprehensive Guide for Professionals https://www.ncoa.org/article/the-medicare-appeals-process-a-comprehensive-guide-for-professionals

13:09:09     From Louis P Sokol : Thanks for an amazing webinar. This is scary stuff that affects so many people.

13:09:17     From Gelareh Bassiry : This was great, thank you

13:09:22     From Kimberly Hughes : Thank you