Medicare Denial- How to Proceed?

Non-investing personal finance issues including insurance, credit, real estate, taxes, employment and legal issues such as trusts and wills
Post Reply
User avatar
HankN50511
Posts: 2
Joined: Sat Apr 16, 2016 11:02 pm
Location: Pacific Northwest

Medicare Denial- How to Proceed?

Post by HankN50511 » Wed Apr 25, 2018 11:27 pm

My wife's first labs under Medicare (for a very long chronic illness) were denied by Medicare.

Labs are routine for this specific illness; nothing out of the ordinary. Other patients in the same doctors' office were not denied for the very same labs!

Her doctor appealed one lab, which was allowed. Two other labs are still denied. Her doctor will not write another appeal. The lab fee is very expensive.

We cannot talk to anyone knowledgeable at Medicare. The contractor for Medicare (CMS) does not talk to patients.

Any suggestions on how to cut through the bureaucratic nightmare so that her labs may be paid by Medicare?

Thank you.

dbr
Posts: 27207
Joined: Sun Mar 04, 2007 9:50 am

Re: Medicare Denial- How to Proceed?

Post by dbr » Thu Apr 26, 2018 9:07 am

Starting at any of the Medicare web pages https://www.medicare.gov/claims-and-appeals/index.html there are procedures for appeals. I know all the statement of benefits that I see coming through have a page of notes on how to appeal denials. I am not sure why the doctor is appealing as the patient is the person who has position to appeal. Brief reading shows a five layer process for continued appeals. Normally assistance from the doctor is required to document the facts, but the appeal comes from the insured person.

I am not experience appealing Medicare claims, but from experience with the appeals process with other branches of the Federal Bureaucracy I know that success may eventually require assistance of an attorney specializing in the issue. Whether or not enough money is involved to justify this is a legitimate dilemma.

Another question is whether your wife has a Medigap policy. Generally Medicare by itself is not adequate health insurance.

btenny
Posts: 4499
Joined: Sun Oct 07, 2007 6:47 pm

Re: Medicare Denial- How to Proceed?

Post by btenny » Thu Apr 26, 2018 9:47 am

Medicare is a PIA about routine blood tests and doctor office visits in less that 1 year or so for normal illnesses that need to be monitored. They will pay for tests for a doctor to search for a new diagnosis but not for return tests for the same thing next year unless you wait for 1 years plus a day and get new doctor orders each time. I have to ask the testing company and the doctors before i get any blood test run to make sure I have not had that test done in the last year.... They are the same way about annual doctor visits and those costs as well. They will not pay for routine doctor visits in less than 1 year for my illnesses..

So check your dates and schedule accordingly. Good Luck.

User avatar
Pajamas
Posts: 6015
Joined: Sun Jun 03, 2012 6:32 pm

Re: Medicare Denial- How to Proceed?

Post by Pajamas » Thu Apr 26, 2018 10:52 am

Why were the claims denied?

What was the basis for your doctor's successful appeal?

Is this original Medicare or is it a Medicare Advantage plan?

likegarden
Posts: 2665
Joined: Mon Feb 26, 2007 5:33 pm

Re: Medicare Denial- How to Proceed?

Post by likegarden » Thu Apr 26, 2018 1:38 pm

We have Medicare and a Medicare Advantage policy, actually is an HMO policy. Once a while I see that several 100 dollars of lab bills are not approved, but because of our HMO policy, we let Medicare, the lab and my insurance fight that out. The lab and doctor should know how much they may charge for what, and tell you if there could be a problem, and discuss that with your insurance. Perhaps something was not coded correctly.

Katietsu
Posts: 1547
Joined: Sun Sep 22, 2013 1:48 am

Re: Medicare Denial- How to Proceed?

Post by Katietsu » Thu Apr 26, 2018 3:14 pm

Please note that you have a limited time to appeal. Watch the dates.

Grasshopper
Posts: 900
Joined: Sat Oct 09, 2010 3:52 pm

Re: Medicare Denial- How to Proceed?

Post by Grasshopper » Thu Apr 26, 2018 3:58 pm

If a lab procedure is "medically necessary", I have never had one denied. I have PSA tests done twice a year no problem, so I am not sure about the 1 year one day rule. :beer

kaneohe
Posts: 4957
Joined: Mon Sep 22, 2008 12:38 pm

Re: Medicare Denial- How to Proceed?

Post by kaneohe » Thu Apr 26, 2018 5:12 pm

likegarden wrote:
Thu Apr 26, 2018 1:38 pm
........................................ Perhaps something was not coded correctly.
Often denials are because the doctor's office coded something incorrectly.

User avatar
HankN50511
Posts: 2
Joined: Sat Apr 16, 2016 11:02 pm
Location: Pacific Northwest

Re: Medicare Denial- How to Proceed?

Post by HankN50511 » Sun Apr 29, 2018 2:16 pm

Thank all of you for your kind responses.

My wife has original Medicare B and BCBS Regence secondary insurance.

She has a chronic rare illness, Adult Growth Hormone Deficiency.
Medicare accepted the diagnosis in 2017 when my wife turned 65. Medicare also approved injectable growth hormone at that time.

It is customary to monitor the deficiency with a number of lab tests, as often as every three months. The growth hormone deficiency can cause complications in other organs, including non-insulin diabetes or type 2 diabetes. The HA1c lab test is medically necessary.

Medicare had originally denied two specific tests to monitor her growth hormone. The doctor appealed, and Medicare allowed one of the lab tests.

At the time of that appeal, Medicare adjusted (retroactively denied) a previously approved A1c lab. The A1c test was coded correctly.

The doctor has reduced her labs and visits to once every six months due to Medicare reluctance to approve labs. His medical assistant has said they will do the A1c lab in the office and charge $11. This has not happened with his other growth hormone deficient patients, who are also on Medicare.

My wife’s concern is, without a successful appeal, a precedent is being established for Medicare to continually deny customary labs for this illness.

This A1c lab was the first one performed for my wife under Medicare. They have no explanation on the form they sent other than they “adjusted” the payment. It seems like they went fishing for dollars. The Medicare handbook says any patient is allowed two A1c labs a year if it is a “screening,” as opposed to a “diagnosis” of diabetes.

The doctor is apparently too busy to appeal this lab, thus my wife is changing doctors.

Thank you again.

User avatar
Pajamas
Posts: 6015
Joined: Sun Jun 03, 2012 6:32 pm

Re: Medicare Denial- How to Proceed?

Post by Pajamas » Sun Apr 29, 2018 7:15 pm

HankN50511 wrote:
Sun Apr 29, 2018 2:16 pm
The Medicare handbook says any patient is allowed two A1c labs a year if it is a “screening,” as opposed to a “diagnosis” of diabetes.

The doctor is apparently too busy to appeal this lab, thus my wife is changing doctors.
It sounds like the denial was technically correct, then.

If guidelines for monitoring patients with your wife's condition and treatment indicate a necessity for checking blood glucose more frequently than twice a year, then the new doctor could appeal on that basis. Rules like that are usually general and there are almost always appropriate exceptions.

Sometimes it is possible to substitute one test for another, such as fructosamine for HgA1c. That's something else the doctor could consider if an appeal is denied.

User avatar
LadyGeek
Site Admin
Posts: 47502
Joined: Sat Dec 20, 2008 5:34 pm
Location: Philadelphia
Contact:

Re: Medicare Denial- How to Proceed?

Post by LadyGeek » Sun Apr 29, 2018 7:33 pm

This thread is now in the Personal Finance (Not Investing) forum (insurance).
Wiki To some, the glass is half full. To others, the glass is half empty. To an engineer, it's twice the size it needs to be.

mac808
Posts: 472
Joined: Mon Sep 19, 2011 8:45 pm

Re: Medicare Denial- How to Proceed?

Post by mac808 » Sun Apr 29, 2018 8:37 pm

First, don't be too hard on the doctor - they aren't paid extra for the appeal and it can be extremely time consuming, not to mention frustrating. If they appealed every denial, they would go out of business.

Second, for all those reading this thread - this is the future of medicaid/medicare for many of us. I consult in clinical practice settings and see properly coded, medically indicated lab tests and imaging denied ALL THE TIME. The reviewers have no liability if they deny and it turns out they made the wrong call. Action item: plan to pay out of pocket for these tests. The good news is that these tests are becoming more competitive and you can find decent prices online. But you may still need to budget a couple hundred dollars per month to cover blood tests privately, more for imaging (which you should need less frequently).

toofache32
Posts: 1293
Joined: Sun Mar 04, 2012 6:30 pm

Re: Medicare Denial- How to Proceed?

Post by toofache32 » Sun Apr 29, 2018 8:46 pm

Grasshopper wrote:
Thu Apr 26, 2018 3:58 pm
If a lab procedure is "medically necessary", I have never had one denied. I have PSA tests done twice a year no problem, so I am not sure about the 1 year one day rule. :beer
How do you determine if something is "medically necessary?"
"Medical necessity" is an insurance designation, not a physician's designation. The insurance company decides if it's "medically necessary". Many people think the doctor can write a letter declaring something "medically necessary" and the insurance company will suddenly pay for it.

Post Reply