It’s up to you to stick up for yourself.
According to a new report for the U.S. Inspector General, "Medicare Advantage Appeal Outcomes and Audit Findings Raise Concerns About Service and Payment Denials," there are “widespread and persistent problems related to denials of care and payment in Medicare Advantage” plans, which usually are managed-care HMO or PPO plans.
But the good news is, when people fought back via the appeals process, 75 percent of their claims were paid.
Make sure your claim is “clean”
Procedure codes (CPT codes) need to be correct, with the appropriate billing modifiers (if necessary), attached to the CPT code, as well as the correct diagnosis codes (ICD10 codes). Demographic information of the patient must be correct too. The name on the claim needs to match the name on the insurance card (Tom vs. Thomas), correct date of birth, sex and ID number.
“An insurance company will deny a claim even if one digit or one letter is off on the ID number,” says Maria Montecillo, a medical cost advocate in Wyckoff, New Jersey.
For surgical claims, attach the report that gives details of the operation and results, and the pathology report to the claim, as these may be requested later by the insurance company. Give it to them up front. “Some insurance companies will automatically deny a claim for no reason, ‘pending review’, other than the amount billed is over five figures,” says Montecillo.
What to do
When a claim is denied, review the original submission. Correct errors and resubmit the form.
If you don’t understand why you were denied, call the insurance company’s claims department for more information. Find out if the “reason” is appealable and if so, write an appeal letter. Do ask for a reference number for your call and the name of the person you’re speaking with, so you can name them in your appeal letter.
Build your case. Discuss the denial with the physician who ordered the treatment. “For example, ask her or him if there is evidence-based literature supporting use of the treatment that should have been taken into account by your Advantage plan,” says Ruth Linden, founder of Tree of Life Health Advocates in San Francisco.
Find out the time limit for filing a claim appeal, typically 30 to 90 days.
“Be cognizant of this deadline," Montecillo warns. "Once it’s passed, you have no grounds for appeal whatsoever.”