Claims Questions And Appeals

I have been a health insurance broker for over a decade and every day I read more and more "horror" stories that are posted on the Internet regarding health insurance companies not paying claims, refusing to cover specific illnesses and physicians not getting reimbursed for medical services. In both cases, you start by appealing to the plan, rather than to Medicare. Older adults can become discouraged as they go through the early steps of this process, but we encourage them not to give up — people are often successful at higher levels of appeal,” Schwarz said.

Payment for a health care service, certain supplies, a particular item, or a prescription drug you already received. A decision about whether we will cover a Part D prescription drug can be a standard coverage determination. In addition, Medicare Advantage companies must give patients a way to report grievances about the plan and the quality of care they receive from providers in the plan.

If we agree with our original determination, the appeal will automatically be sent to Maximus Federal Services for review. One of the principles behind MA is that plans could save Medicare money by reducing utilization before services are rendered, in contrast to Medicare's familiar pay-and-chase” model.

The process for coverage decisions and making appeals deals with problems related to your benefits and coverage for medical services, including problems related to payment. On the basis of the sample, the OIG estimated that Etheredge received $169,737 in unallowable Medicare payments for CYs 2014 and 2015.

The numbers are particularly troubling because of the infrequency with which beneficiaries and providers used the appeals process — How to Appeal Medicare Advantage Denial for just 1% of denials at the initial appeal level, according to the report. Non-contracted providers can request independent review of a claim (i.e. that a person without a financial stake decide whether or not a claim should be paid).

MAXIMUS is an Administrative Qualified Independent Contractor (AdQIC), providing support to the Centers for Medicare and Medicaid Services (CMS) and the other fee-for-service contractors. There are five levels to the Original Medicare appeals process, and if you decide to undertake this process, you'll start at Level 1.