How are Medicare Claims Handled?
Claims for health care payments under Medicare are handled by private insurance companies. Although Medicare most often does not pay the full cost of covered health care, it may improperly deny claims altogether; in other words, sometimes a health care provider will mistakenly tell you that it cannot give you a service at all because Medicare does not cover the service. This misinformation can be very expensive for you if you do not act quickly to protect your rights.
What Can You Do if You Don’t Agree with a Hospital’s Decision About Your Need for Hospital Care?
When you are admitted to a hospital, you should receive a notice about your rights as a hospital patient. You have special appeal rights if you think you are being discharged from the hospital too soon. A hospital cannot use the amount of the Medicare payment under the Diagnostic Related Groups, or DRGS, to decide how long you need inpatient care. The DRGs represent
average times for hospital stays. They do not take into account your personal rate of recovery or any other health problems you may have that have an impact on your condition.
To appeal the length of time allowed for your hospital stay, you (the hospital patient) or your family must ask for a written notice of when the time is up. Once you get the “Notice of Noncoverage” and it seems unreasonable, you or someone representing you have 24 hours in which to call the Quality Improvement Contractor (“QIC”) at the number on the notice as soon as possible to ask it to reconsider. The QIC will issue a decision within 24 to 72 hours. You may be billed for all costs of your hospital stay beginning at noon of the day after you receive the QIC’s decision, unless the QIC decides you still need hospital care. By that time, your condition may have improved enough for you to go home safely anyway. If it hasn’t, you can get additional review. At this point, it will be important for your doctor to become involved in explaining your continuing medical needs.
The QIC for Oregon is Acumentra Health,
www.Acumentra.org; telephone: (503) 279-0100 or (800) 844-4354.
If the QIC agrees with the hospital’s decision, you can ask for a reconsideration by contacting the QIC by phone or in writing. Since the QIC has already reviewed your case once, the hospital is permitted to begin billing you for the cost of your stay beginning with the third calendar day after you receive a notice of noncoverage.
If you disagree with the quality improvement contractor’s decision on reconsideration, and the amount in dispute is $120 or more, you can ask for a hearing before an administrative law judge from the Center for Medicare and Medicaid Services. You have 60 days from the day you receive the notice of the reconsideration decision to request a hearing in writing. If there is $1,220 or more in dispute, the administrative law judge’s decision can be reviewed by a federal court. Note that these minimum amounts change as the official cost of living changes.
What If I Disagree with a Coverage Decision About My Medicare Benefits?
You may have questions or disagree with a decision about a Medicare payment. Medicare notifies you each time a decision is made on paying for services you received.
For a claim under Part A or Part B in Oregon, Acumentra Health sends out a Medicare Benefit Notice. It will list any services that are not being covered by Medicare and give the reasons payment was denied. You can call the office listed on the notice and request an explanation. If you disagree with the decision, you have 120 days from the date you received the denial notice to make a written request for a redetermination. You can send evidence to support your case. The organization has 60 days to issue a new decision. If it denies your claim again or if it does nothing in that time period, you can ask for a reconsideration by a different review team. You have 180 days to ask for the reconsideration. Acumentra has 60 days in which to review the claim. If it denies your claim again or has not made a decision within that time, Medicare law says that the claim is “deemed” to be denied. Thus, after 60 days, you can appeal to the next level, an administrative hearing– but only if the amount in dispute is $120 or more. You are allowed to combine claims of smaller amounts to reach this minimum. You have 60 days from the date you received the reconsideration decision notice to make a written request for a hearing. The hearing will be held by an administrative law judge from the Center for Medicare and Medicaid Services (CMS). You may have a lawyer or someone else represent you at the hearing. You may also bring evidence and witnesses to testify for you at the hearing. The administrative law judge’s decision can be reviewed by the Medicare Appeals Council. If the denial involves $1,220 or more, the denial may be appealed to federal court. These dollar limits will change whenever the official cost of living changes.
When a Health Maintenance Organization or HMO or another type of Medicare Advantage managed care program is involved, the process is different. If the HMO refuses to provide a service that you believe is medically necessary, the HMO has 14 days in which to make a determination about whether its decision was correct. It has 30 days to review its denial of service. If your condition would worsen seriously if the HMO does not provide the care you need, you can ask for it to expedite its decision.
If your HMO denied coverage for care you have already received, you have 60 days from the date you receive either type of denial notice to make a written request for reconsideration by the HMO. If the HMO supports the original denial, it must send your request to an outside organization called, an independent review entity, to review the claim again. The review entity will then send you its decision.
If you don’t agree with the reconsideration decision, and the amount in dispute is $120 or more, you can ask for a hearing. You have 60 days from the date you received the reconsideration decision notice to make a written request for a hearing with an administrative law judge from the Center for Medicare and Medicaid Services. Unlike in a regular Medicare appeal, the hearing judge does not have any time limit in which to make a decision in your managed care case.
If there is at least $1,220 at issue, the decision by the administrative law judge can be appealed to federal court.
If you need assistance understanding Medicare paperwork, submitting claims, or organizing your bills, you can get free help from the state of Oregon’s Senior Health Insurance Benefits Assistance (SHIBA) program. To get assistance or referral to a SHIBA volunteer, call toll-free (800) 722-4134.
What Can You Do if You Don’t Agree with a Decision About Your Need for Skilled Care in a Nursing Home?
If you are admitted to a nursing home and Medicare is paying for skilled care, your condition will be reviewed frequently. If you are receiving rehabilitative services, the facility may refuse to continue them because you are not improving fast enough, for example. If you are told you no longer need or are no longer entitled to skilled care, you should receive a written notice explaining why, and telling you how to appeal the decision. If you think you still need skilled care at least five days per week, or if you think you need rehabilitation services to keep your condition from getting worse, you or someone representing you can call the quality improvement contractor to ask it to reconsider. If the QIC upholds the nursing home decision, you may be billed for the cost of your nursing home stay after that. The telephone number for the QIC for Oregon is (503) 279-0100 or (800) 344 4354.
Legal editor: Janay Haas, October 2009
