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Appeals

The initial notice that a Medicare recipient receives informing him or her that payment is being denied by the insurance company is by way of a form misnamed an “Explanation of Medicare Benefits.” This form is misnamed because it does not provide much of an explanation. It is often extremely difficult to comprehend and may not even provide a clear explanation as to the specific reason for the denial.

For a while it seemed everyone was parroting Regis Philbin’s oft-repeated line from Who Wants to Be a Millionaire?: “Is that your final answer?” When it comes to denials of Medicare coverage, it may make sense to repeat that sentence again. Decisions as to coverage of particular medical treatments may be denied as not being “medically and reasonably necessary.” Appeals of coverage decisions of the insurance companies managing Medicare or the decisions of physicians who make up “peer review organizations” to determine care decisions in hospitals are something that can be done quite successfully. Although few people actually appeal denials of care, HCFA federal government figures for the years 1999 and 2000 showed that 30.3% of the Medicare Part A claim denials were overturned on appeal in favor of patients and that 65.6% of Medicare Part B claim denials were resolved in the appealing patients’ favor.


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