Recently our Client Service Team assisted a long-time client with filing an expedited appeal. Within 72 hours, the insurance carrier reversed their original decision and gave our client approval for the care he needed.
It’s the kind of thing that makes your day every single time it happens. You’ve helped someone through something that potentially could have been costly for them.
Medicare bills sometimes get denied, especially when you are on a Medicare Advantage plan. Read on to see how we handed this particular denial.
Why Joe’s Bills Got Denied
In this case, our 90-year-old client, (we’ll call him Joe) had been discharged from the hospital into a Skilled Nursing Facility. Weakened from a prolonged illness, Joe was unable to attempt therapy. The Medicare Advantage carrier then denied payment for the Skilled Nursing Facility (SNF). Their denial stated that Joe had “refused to participate” in therapy that would begin his rehabilitation.
Medicare generally does not provide skilled nursing facility care for beneficiaries who are not expected to recover. It will cover up to 100 days in a SNF, with the goal being that the beneficiary can then resume normal self-care. Medicare Advantage plans follow these same rules.
It appeared Joe was refusing to try to get well, so the carrier actually did have grounds to deny the claim. However, the physical therapist’s notes upon which the carrier based their denial did not tell the whole story.
When Joe’s daughter – let’s call her Mrs. P – called to tell us what happened, our Client Service Team stepped in. We gathered all the necessary data to launch an appeal. We directed Mrs. P to obtain copies of all the physical therapy notes from her father’s sessions. We then asked for copies of the carrier’s denial letter.
What Really Happened
We were quickly able to piece together what had happened. Joe was admitted to the hospital not long after a fall. The fall had caused him to break his arm and bruise his back. Upon admittance to the hospital, he was diagnosed with low blood pressure, low oxygen and a severe and debilitating UTI.
This infection, coupled with the pain medication he was given, had left him feeling weak, foggy and confused. The hospital started a high dose round of antibiotics until he stabilized. Then they transferred him to the SNF.
Mrs. P reported that within a few days the antibiotics had begun to get his infection under control. His strength returned. He then felt alert enough to participate in therapy and was now making steady progress. She collected copies of the more recent physical therapy notes for us. This indeed showed his full participation in therapy, although he was not yet ready to be released.
We wrote an appeal letter demonstrating that our client was too ill to perform PT. We stated that in all likelihood, he probably shouldn’t have been discharged from the hospital. Mrs P. provided the back-up of the physical therapist’s notes showing the turnaround Joe had made. We sent the rough draft of the letter to Mrs. P who reviewed it for accuracy. She added her own notes and comments. Then she submitted the letter to the carrier’s 72 hour expedited appeal fax line that we provided to her.
The denial for skilled nursing care was overturned. Better yet, they made it retroactive to the first date our client had entered the facility. This saved him thousands of dollars in facility charges.
Steps to Filing an Appeal – Timeline, Document, Facts
We’ve helped many clients with similar circumstances over they years. We have learned that there are several critical steps to filing a Medicare appeal that will have a chance.
The first step is to put together a timeline. You can use the Explanation of Benefit statement that your insurance company sends you after each medical service. This document will reflect claims by date. It will also show you the codes the company used when it denied your claim. In this case, the denial was for refusing participation in therapy. So we knew we needed to argue against his refusal being valid. He didn’t refuse to cooperate because he was stubborn or uncooperative. He refused because he physically couldn’t even stand up.
The second step is to get your healthcare providers to give you any backup documentation that might help you. Often the medical notes can help, as they did in this case. For example, get your doctor to write a supporting letter as to why he prescribed something. You can use this to argue for medical necessity, etc.
Finally the Medicare appeal letter itself should include all relevant details. Outline the facts and dates of service and any doctor’s orders that affect your claim. Keep it professional. When Medicare or an insurance company denies a claim, we become angry or emotional. It’s all too easy to let that overwhelm our appeal letters. However, you catch more flies with honey. Remember that a human being will read this appeal. Be respectful by simply stating your case so they can see the solid facts you are providing. The claims examiner will base his or her decision on facts, so writing a straightforward non-emotional letter based on facts are in your best interest.
A Special Note on Part D Maximus Appeals
Many people these days work past age 65 and delay enrollment into Parts B and D until they retire. Later on when they retire and enroll in Part D, Medicare sends them a form through their new Part D carrier. The form asks that you list any other creditable coverage you have had since age 65.
This is how Medicare determines if you owe a penalty for late enrollment into Part D.
Sometimes people miss this letter and mistakenly throw it away. The carrier will often send it more than once. If they get no reply, they notify Medicare and Medicare assesses a late penalty. When Medicare does this, the Part D carrier MUST comply. They must charge you the penalty – they have no choice.
TIP: This form will usually give you a choice between calling the Part D carrier to report the information or mailing the form back to them. I suggest you do BOTH.
Here’s why: We have seen cases where the member says they returned the form but the carrier did not receive it. We have also seen errors where the Part D carrier processed the form incorrectly, or failed to report the client’s call-in, and a penalty was charged when it is not actually owed. So frustrating, I know.
While it’s not common, it happens more often than it should.
No matter how the failure to record creditable coverage happened, you, the Medicare beneficiary must now appeal to Maximus, which is the company that handles Part D appeals for our federal government. (You can complain the Part D insurance company and it will get you absolutely nowhere, so save yourself the hassle and move on to the appeal).
Here are the steps you should take:
- Complete the Late Enrollment Penalty Reconsideration Request Form which can be found on the Maximus website here. Give them as much detail as possible about your prior coverage – preferably a letter of creditable coverage from your former insurance company that shows the dates you had employer coverage. Also, if you did send in the letter to the carrier initially with your creditable coverage and the insurance company failed to record it, then report that to Maximus as well.
- Mail or fax the form and supporting documents to Maximus.
- Continue to pay the Part D penalty while Maximus processes your form. This can sometimes take MONTHS. Unfortunately, you must wait it out. (Remember, this is the federal government we are dealing with here). If they decide in your favor, you will be credited back for penalties paid in the meantime.
I wish I could tell you that your insurance agent could speed up this process, but we are powerless once it gets to this level. Every person, no matter who they are, goes through this same process and has to wait it out. There are no exceptions. This is a very frustrating thing for both you and US because we have no recourse other than to help you find the appeal form and give our advice on what to include when filling it out.
If Maximus denies the appeal, it is unlikely that the penalty will ever be waived. However, there may be additional appeal levels that you can try. Take it one step at a time.
Enlist the Help of your Medicare Insurance Agent
If you purchased your Medicare-related insurance policy through an insurance agent, reach out to that agent for help. Not all agencies help their policyholders with appeals but some will coach them on best practices.
Finally, remember that even the ones that do, like our agency, can’t guarantee that you will always win. You can however give yourself the best chance by following the simple tips outlined here today and using any resources available to you.
If you’d like to learn more about our Client Service Team, don’t hesitate to contact us. Our agency is happy to coach our existing policyholders with how to file appeals and what things to say or do to give yourself the best chance.
While we cannot assist individuals who did not enroll through us, we hope the tips in this blog post will help non-clients with how to go about appeals on their own.
***NOTE: We get many questions on this page about appeals from our internet readers. We cannot answer specific questions here about personal situations due to privacy, and also because it’s impossible to offer advice without reviewing all of the relevant data.
Please note that our agency cannot assist you any appeal unless your purchased your policy through Boomer Benefits. It against insurance licensing laws for us to advise individuals where we are not the agent of record on the policy. If you need help on an appeal situation in progress, we advise that you contact your insurance agent who wrote your policy for personal assistance.***