Steps to Take If Your Medical Claim is Denied

Steps to Take If Your Medical Claim is Denied
 
You probably have heard that Medical claims sometimes get denied by insurance companies.  Sometimes, the insurance company denies the claim simply because Medicare or the policy does not cover that service.  Sometimes, there are coding errors.  Coding errors and incomplete information account for 5-15% of all claim denials. Sometimes, claims may get denied that maybe shouldn’t have been denied.  Here are some ways to make sure that you’re getting the appropriate care. Please note that appeals typically have strict deadlines, so it’s important to act promptly.
 
Understand the Denial and Correct any Potential Errors
Read the Explanation of Benefits (EOB) or denial notice from your insurance company and make sure that it explains why the claim was denied.  If not, call the insurance company for an explanation. Look at your insurance policy to understand coverage terms and see if the denial aligns with your plan’s rules.
 
Sometimes denials are due to errors or missing information that can be resolved quickly. Ask your healthcare provider to ensure that they submitted the correct procedure and diagnostic codes, as well as any additional medical records, physician’s notes, or referrals if requested.
 
Get Assistance from Your Insurance Agent and Advocacy Groups
One of the reasons to use a local independent insurance agent is that you have someone that knows you and is the same person available to you all year round that you can count on to be your advocate.  However, if you don’t have a trusted local agent, you can receive free guidance from organizations like the State Health Insurance Assistant Program, the Medicare Rights Center, the Center for Medicare Advocacy, or the Patient Advocate Foundation (PAF.) You can also call 1-800-Medicare and request to speak to the Medicare Beneficiary Ombudsman.
 
File an Appeal with your Insurance Company
There are 5 levels of appeal in Medicare health plans, not to be confused with Dante’s 9 Circles of Hell. After Level 2, you might want to hop on over to the section of this article on Constituent Services.
 
Level 1 Appeal is you will call the insurance company and tell them that you want to file an Appeal.  Follow your insurer’s appeal process. This usually involves filling out forms and providing supporting documents.
 
If your plan upholds their denial in your level 1 appeal, they’ll automatically forward their reconsideration decision to an Independent Review Entity (IRE) to start a level 2 appeal.
 
If you disagree with the IRE's decision in level 2. You have 60 days from the date of the IRE’s decision to ask for a level 3 appeal, which is a?decision by the Office of Medicare Hearings and Appeals (OMHA). Visit Medicare.gov and search for “appeal” for full details on all the levels.
 
 
 
The Role of Constituent Services in Resolving Denied Claims
Constituent services, often provided by elected officials like members of Congress, can be a valuable resource when facing a denied claim. Most offices have a specific email address or phone line for constituent services.  These offices can leverage authority to advocate for their constituents.  No insurer wants to be the example of why a new law had to be introduced.
 
Contact Your Representative:
To identify your Federal Legislators, visit www.congress.gov to find your U.S. Representative and U.S Senators by entering your address.  These representatives handle issues involving programs like: Employer-sponsored health insurance (governed by the Department of Labor), Medicare, Medicare Advantage, Medicare Part D (Drug Plan), TRICARE, and VA health programs.
To find your State Legislators, visit your state legislator’s website or www.usa.gov/elected-officials to find your State Representative and State Senator.  State legislators often assist with: Medicaid, ACA Individual Marketplace plans, (co-regulated by state and federal governments,) Dental, Vision, and other Ancillary benefits.
 
Legislators’ constituent services teams act as intermediaries between you and the organizations or government entities causing the issue.  They have established contacts and processes to escalate cases, and while they cannot guarantee an outcome, elected officials’ inquiries can sometimes prompt faster reviews or re-evaluations of claims, ensuring you receive appropriate benefits.
 
For Federal Programs, Legislators can press insurers and plan sponsors by working through federal agencies such as the Department of Labor or CMS (Centers for Medicare & Medicaid Services.)
For State or Joint Programs, State legislators can coordinate with state Medicaid offices or insurance commissioners.
 
Tips for Working with Constituent Services:
Be prepared to share detailed information and documentation about your claim, denial, and any correspondence with the insurer or provider.  You will likely need to sign a privacy release form allowing the representative’s office to act on your behalf. Follow Up and keep in regular contact with the representative’s office to track progress and provide updates. Be patient but persistent.
Utilize both State and Federal offices: Depending on the program, one office may be more effective than the other.
 
Including constituent services in your efforts to resolve a denied claim can add a layer of advocacy and visibility that may help expedite resolution.  If your issue is resolved, let your legislator’s office know and share your story to help others know about their services.
 
 
 
 
 
 
Steps for Filing a Complaint Against a Medicare Advantage Company
If you are dealing with a denied claim or poor service from a Medicare Advantage company, you can file a grievance.  This is different than an appeal asking them to review the denial.
 
Call your plan's Member Services department (the number is on your Medicare Advantage card or plan materials). Inform them of the issue and ask them to file a formal grievance. You can typically do this by phone, in writing, or online, depending on the plan.
 
Prepare Supporting Information including your name, Medicare number, and contact information. Give a clear description of the issue, including dates, times, and names of people you interacted with; Copies of related documents (e.g., bills, correspondence, EOBs). And make sure to meet the deadline. Medicare requires grievances to be filed within 60 days of the event causing the complaint. Some plans may allow more time.
 
Ask the plan to confirm receipt of your complaint and provide a written resolution. Plans are required to respond within 30 days, or within 24 hours for urgent cases.
 
By following these steps and utilizing available resources like Constituent Services and Medicare advocacy programs, you can address a denied claim or grievance with your Insurance company and ensure that your concerns are resolved. Stay organized, act promptly, and seek assistance when needed to improve your chances of success.
 
Mary Hiatt is a Retirement & Insurance Advisor and President of Mary the Medicare Lady (A
non-government entity.) She offers Educational Workshops on Medicare, Drug Savings, and
more at no charge. Not connected with or endorsed by the U.S. government or the federal
Medicare program. Medicare Supplement insurance plans are not connected with or endorsed
by the U.S. government or the federal Medicare program. See www.hiattagency.com or contact
licensed independent agent mary@hiattagency.com or call or text 402 672 9449 for more
information.