04 Medicare Appeals
With nearly 84% of physicians accepting Medicare patients, Medicare timely filing denials can affect almost any provider. If we deny your exception request you can appeal our decision. There are up to five potential levels of standard appeals that a Medicare Advantage Plan member can pursue for a Medicare Part C denial. If your appeal is denied and your drug is worth at least $160 in 2018, you can choose to appeal to the Office of Medicare Hearings and Appeals (OMHA) level within 60 days of the date on your IRE denial letter.
HealthCare Partners Holdings, a subsidiary of DaVita Inc, one of the nation's largest dialysis clinic networks recently paid the federal government $270 million to settle claims that the company overexaggerated how sick their patients were in order to inflate government payments.
If a doctor is not appealing on your behalf, you may want to ask your doctor to write a letter of support addressing the plan's reasons for not covering the needed drug. Importantly, the OIG found that Medicare beneficiaries and providers only appealed 1 How to Appeal Medicare Advantage Denial percent of denials.
You can also get a fast coverage decision if it is determined that using the standard deadlines could cause serious harm to your health or hurt your ability to function. But this time, your appeal goes to an independent organization that works for Medicare. In addition, it notes that even when CMS audits show widespread wrongful denials by Medicare Advantage plans, they do not affect a Medicare Advantage plan's star ratings.
The findings reveal concerns about service and payment denial among Medicare Advantage, which covers more than 20 million Medicare beneficiaries in 2018. In some cases, the ALJ may decide to forgo a hearing altogether and may decide the case on-the-record†when the evidence in the claim file supports a decision in your favor.
The high rate of success in the appeals process demonstrates two troubling issues: (1) many denials by Medicare Advantage organizations are initially incorrect and unsupported; and (2) providers and beneficiaries who don't appeal may be missing out on services or payment to which they are entitled.