For those who are enrolled in Medicare, there may come a time when you have some type of issue with your coverage. This may come in the form of a denial of a claim, or with the type or amount of care that you have received. It’s important, as a medicare recipient, to know your rights and how you can go about exercising them.
Regardless of whether you are enrolled in Original Medicare (which consists of Medicare Part A and Medicare Part B) or Medicare Advantage (Medicare Part C), issues do come up. There are a lot of moving parts inside of Medicare and health care, which means that is a good chance that someone can mess up along the way. Mistakes happen, but when you’re dealing with medical bills and health care coverage, those simple mistakes could have serious consequences. There are also times when there are problems with Medicare Part D, prescription drug coverage. In any case, you have a right to accurate information from Medicare, as well as the right to file a complaint.
In a majority of instances, you may be able to get your issue resolved by directly contacting the Centers for Medicare and Medicaid Services. You can do so by either calling their toll-free telephone line or by going through the Internet to their website. For the majority of cases, getting the mistake corrected is simple and quick.
Issues that are typically resolved here may include the following:
- Questions regarding payment and billing
- Coverage issues regarding medical services and supplies
- Questions regarding locating medical providers and medical suppliers who accept Medicare in your local area
- Questions regarding the appeal of a payment or a coverage decision that you do not agree with
- The reporting of Medicare fraud
These are just a few of the things that can be resolved by simply calling your local Medicare professionals. If it can’t be resolved, they will be able to point you towards other avenues, which we will discuss later.
There may be circumstances where you will have to go through an appeals process. In this instance, if you feel that an error has been made, you can request what is known as “equitable relief.” Equitable relief is a procedure that allows Social Security to investigate cases, and to reverse decisions that it finds to have been caused by a federal employee making a mistake or providing a Medicare enrollee with incorrect information. Don’t worry, the process isn’t as difficult as it sounds. There are plenty of professionals that can help you through that process if you need additional assistance.
If you do need to go through the appeals process in order to resolve a particular issue, there are several steps that will need to be taken. The first of these is filing a grievance. A grievance can cover many types of complaints that a person may bring against either Medicare Advantage or Medicare Part D plans. These focus primarily on the plan’s service or its quality of care, and the grievance will require that some type of action be taken from the plan in order to have it resolved.
Some examples of these situations may include:
- The receipt of poor quality service
- Receiving incorrect information from the plan’s customer service representatives
- Receiving no information at all from the plan (especially when information was required in certain instances)
- Receipt of late responses or decisions from the plan
The other step in the appeals process involves the request of a coverage determination. This step is always related to issues of coverage and / or payment. For those who are enrolled in Original Medicare (Medicare Part A and Part B), a determination can be obtained for any service or item in the traditional fee-for-service program in one of two ways. These can include:
- Checking your MSN (Medicare Summary Notice) – Your Medicare Summary Notice, or MSN, is the statement that is sent to you from Medicare every quarter that is a record of the services that you have received during that period of time. If you happen to notice a service or an item that Medicare has denied payment for, the denial means that the determination has already been made by Medicare. In order to appeal this particular decision, you will need to file within 120 days, following the detailed instructions in the MSN notice.
- Checking the first option on an Advanced Beneficiary Notice of Non-Coverage – You may receive an Advanced Beneficiary Notice of Non-Coverage by any medical providers if they believe that Medicare will not cover the service or the item that you are requesting from them. By checking the first option on that notice, you will basically be asking for a coverage determination.
In any case, it is essential that you have a plan in mind before you move forward with an appeal. In doing so, here are some helpful tips that may provide you with a better chance of success:
- Be sure that you have as many supporting documents as possible to help your case
- Have everything in writing so that all details are clear and fresh in your mind
- Keep any and all of the paperwork that you receive from Medicare and the service providers regarding the issue at hand
- Make notes of any in person or telephone conversations regarding the incident
It will also help that you know and understand your rights as a Medicare enrollee.
People make mistakes. It could be a simple filing error, or it could be much larger than that, but regardless this simple slips could end of having dire impacts on your life. Even though many people don’t realize, you have several rights as a Medicare participants. You don’t have to let these errors go uncorrected, even if you’ve been told otherwise. It’s rare that any Medicare professional is going to do something to directly harm you in any way, but if it does happen, the appeal process can bring in additional people to correct those problems.
It’s imperative that you take advantage of the benefits that Medicare offers. As you age, your health is at a higher risk to deteriorate, Medicare is affordable and millions are covered by it. Don’t think that you have to accept any decisions that are made about your coverage.
If you have any questions about your Medicare coverage, Supplemental Plan, or your rights as an enrollee, feel free to contact us at any time. Our aim is getting you the protection you deserve.