March 8, 2010
Troubleshooting Medicare:
Spotting Coverage Notice Issues
On last month's conference call on the Qualified Medicare Beneficiary (QMB) program and Medicare cost-sharing, HAP raised another important beneficiary protection issue — Medicare coverage notices and due process. We're now turning our attention to coverage notices and how they can affect a beneficiary's access to care. This issue has been identified through Troubleshooting Medicare, our ongoing project designed to address systemic issues in the Medicare program.
Coverage notices influence a beneficiary's ability to understand coverage decisions, and to make informed choices as a result of that understanding. Medicare, its payment contractors, and many providers give written notices to Medicare beneficiaries about coverage, payment, and claims. The most common of these notices include:
- Original Medicare Summary Notices (MSN)
- Explanation of Benefit (EOB) statements for Medicare Advantage and Part D drug plans
- Advance Beneficiary Notices (ABN) that include Coverage Termination Notices for Original Medicare and Medicare Advantage
In some cases, these notices do not adequately explain a decision to deny payment or to reduce or discontinue services. In other cases, plans and providers use them inappropriately.
We would like to hear from you about any issues your clients are experiencing around MSNs, ABNs, or Coverage Termination notices. In particular, we want to know if beneficiaries are receiving incomplete or inappropriate coverage decision notices from Medicare's payment contractors, health care providers, or MA plans. The feedback you provide will help us determine the scope of the problem and how it is affecting Medicare beneficiaries.
HAP will document the information and use it to develop policy recommendations for the Centers for Medicare & Medicaid Services (CMS) on how to address some of the underlying due process issues when it comes to inadequate or inappropriate coverage notices. Share your feedback now, and stay tuned for further updates.
Sincerely,
The HAP Team
[Back to Archive | HAP Home]
