How to Help on a Medicare Appeal
1. Understand What’s Happening
a. Find out what service is being denied Medicare coverage and why.
i. Ask if the beneficiary has received any Medicare non-coverage notices.
ii. Look at the notices and, if possible, the envelopes in which the notices were delivered in order to determine whether the notice was delivered in a timely fashion as well as to calculate deadlines for submitting appeals.
b. Decide if there are grounds to appeal the denial
i. You can start to do this by answering the question of whether you believe that the beneficiary met the Medicare coverage criteria for the service being denied Medicare coverage?
ii. Find out what the applicable laws and regulations say about the coverage criteria for the service.
c. HAP’s guide to free online legal and medical research can help you to easily find relevant legal and medical material.
2. Know What Steps To Take and When To Take Them
a. Determine which appeals process is applicable to the beneficiary’s Medicare denial. Is it
i. Traditional Medicare; or
ii. Medicare Advantage; or
iii. National Coverage Determination or Local Medical Review Policy/Local Coverage Determination.
b. Be familiar with the stages of a Medicare appeal and know how, when and where to submit an appeal.
i. Be sure you know what stage in the appeal process the beneficiary’s case has reached when she contacts you.
c. Pay close attention to the timelines of a Medicare appeal. Don’t let the beneficiary miss deadlines!
d. Keep a supply of appeal forms and Appointment of Representative forms so that you can easily help beneficiaries submit the appropriate paperwork. Forms are available on the Medicare web site at http://www.medicare.gov/Basics/forms/default.asp.
e. Make sure the beneficiary keeps copies of all appeals-related documents and mails all appeals forms by “return receipt requested” so that there is a way for you and the beneficiary to know that the appeal was received.
f. Be prepared to help the beneficiary deal with liability and debt collection issues, or know where to refer the beneficiary for assistance with these matters-- for example, legal aid or similar resources in your community.
3. Build the Case
a. Understand the medical factors involved in the beneficiary’s Medicare denial in order to help craft an argument that the service Medicare has denied is reasonable and necessary.
i. Ask the treating physician and other involved health care providers to explain the beneficiary’s medical situation to you. Ask for help understanding why the service Medicare has denied is important to the beneficiary. If you don’t understand, keep asking questions until the medical factors involved in the appeal are clear to you.
ii. You will need to adhere to the HIPAA Privacy Rule when asking health care providers to talk to you and share the beneficiary’s records with you. HAP has additional information about the HIPAA Privacy Rule.
iii. Research the medical factors related to the beneficiary’s Medicare denial.
iv. HAP’s guide to free online legal and medical research can help you to easily find relevant legal and medical material.
b. Work collaboratively with treating physicians and other involved health care providers to strengthen the beneficiary’s case.
i. Ask the beneficiary’s health care providers to prepare and submit supportive letters on behalf of the beneficiary. Letters of support from health care providers should describe the beneficiary’s medical condition and explain why the provider believes that the service Medicare has denied meets all relevant Medicare coverage criteria. Help health care providers to understand that the more fact-based their letters are, the more persuasive weight they will carry in helping to reverse a Medicare denial.
ii. You will need to adhere to the HIPAA Privacy Rule in working with health care providers.
iii. Obtain the beneficiary’s medical records relevant to the Medicare denial and review them to see if the records support the claim for Medicare coverage. Medical records may be submitted into evidence so that they are included in the record of the appeal.
c. Consider attending the appeal with the beneficiary, either as the beneficiary’s representative, or to be a supportive presence for the beneficiary.
4. Support the Beneficiary
a. You can engage in informal advocacy with health care providers and Medicare contractors that might resolve the problem without the need to pursue a formal appeal. For example, you can talk to the provider and the carrier about Medicare coverage criteria and how the beneficiary’s case satisfies the coverage criteria and the beneficiary’s claim should result in an award of Medicare coverage.
i. Medicare contractors are also subject to the HIPAA Privacy Rule.
b. Remain aware of beneficiary liability issues and offer ongoing assistance to the beneficiary throughout the lengthy appeals process.
c. Your support and advocacy can help the beneficiary to deal with the stress and anxiety that the beneficiary may experience while pursuing the appeal.
