Appealing can actually be, well, appealing

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Appealing can actually be, well, appealing

Medicare and Medicaid, which provide medical coverage for seniors, the poor and the disabled, together make up nearly a quarter of all federal spending. With total Medicare spending projected to cost $7.7 trillion over the next 10 years, there is consensus that changes are in order. But what those changes should entail has, of course, been one of the  hot-button issues of the campaign. — Suevon Lee, in Pro Publica article, Where the candidates stand on Medicare and Medicaid, September 14, 2012

                Your doctor suggested you have a minor operation or procedure.  You went ahead and had it done, and now Medicare won’t pay for it.  What should you do?

Remember this word:  Appeal.

Medicare covers procedures that are deemed to be medically necessary.  “Appealing is easy, and most people win so it is worth your while to challenge a Medicare denial,” insists the Medicare Rights Center, a national nonprofit organization.  The denial of coverage may be due, for example, to a simple coding error in your doctor’s office.

People have a strong chance of winning their Medicare appeal.  According to the Center, 80 percent of Medicare Part A appeals and 92 percent of Part B appeals turn out in favor of the person appealing.

The Medicare Rights Center offers the following tips to maximize your success when appealing a denial:

With “Please Review” on the bottom of your Medicare Summary Notice (MSN) sign the back and send the original to the address listed on your MSN by certified mail or with delivery confirmation.

Include a letter explaining why the claim should be covered.

When possible, get a letter of support from your doctor or other health care provider explaining why the service was “medically necessary.”

Save photocopies and records of all communications, whether written or oral, with Medicare concerning your denial.

Keep in mind that you only have up to 120 days from the date on the MSN to submit an appeal.

The appeals process, says MSN, is slightly different if you are in a private Medicare plan, like an HMO or a PPO.  One significant difference is that the appeal window is reduced from 120 days to 60 days from the denial notice.

On the Medicare topic, let’s nail down a few other important pieces of information.  If your doctor tells you he “doesn’t take assignment”, it means he may accept Medicare, but can charge you a little more for the health services you receive.  Doctors who accept Medicare, but don’t take assignment are called non-participating doctors.  Non-participating doctors can bill you a 20 percent coinsurance for Medicare covered services, after your meet your yearly deductible.  Plus, they can bill you an extra 15 percent for the services you receive.  This is called a limiting charge.  Altogether, that mean you may be billed up to 35 percent of Medicare’s approved amount for non-participating providers, after you’ve met your deductible.

Some states have stricter rules on what non-participating doctors are allowed to charge you. Whenever you need to confirm Maryland rules or have Medicare questions, contact SHIP (Senior Health Insurance Assistance Program) at 800-243-3425, and choose option 2.  This office proves comprehensive health insurance information, counseling and assistance for Medicare beneficiaries and older Marylanders.  You can also find them on the state’s Department of aging website,

Most doctors who treat patients with original Medicare do accept Medicare and take assignment.  These doctors are called participating doctors.  Participating doctors agree to accept the Medicare-approved amount as payment in full. The Medicare-approved amount is the amount Medicare has agreed to pay the doctor for services you receive.  When you see a doctor who takes assignment, you will typically pay a 20 percent coinsurance after you meed your annual deductible.

Some doctors just opt out of Medicare.  The doctors are called opt-out doctors and can charge you based on their own fee schedule.  These doctors are required to give you a private contract that states you must pay for the full cost of the services they provide to you.  These doctors do not deal with Medicare, and cannot bill Medicare at all.  You can call 800-633-4227 or go online at to find out whether your doctor is a participating, non-participating or opt-out provider.

Remember, doctor status described above applies only when you have original Medicare.  If you have a Medicare Advantage Plan, you should see doctors and other health care providers in your plan’s network.

The Medicare Rights Center is a national, nonprofit consumer service organization that works to ensure access to affordable health care for older adults and people with disabilities through counseling, advocacy, educations programs and public policy initiatives.  Call them at 800-333-4114, or their website,

Additionally, a favorite organization of mine is the Center for Medicare Advocacy, Inc.  Founded in 1986, this nonprofit, nonpartisan group works to obtain fair access to Medicare and necessary health care for older people and people with disabilities.  Each year the center represents thousands of individuals in appeals of Medicare denials, while responding to thousands of calls and electronic inquires.   There is a wealth of information on this website, and they may be contacted by phone at 202-293-5760.

Thank you for reading.  Stay well.  See you next week.

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