Dear Marci,
I recently went to the doctor for a pain in my foot. He ordered an x-ray that I had the following day. Yesterday I received a denial notice in the mail from my private health plan that said they will not pay for the x-ray. Is there anything I can do?
—Mildred (Bronson, Kansas)
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Dear Mildred,
You can appeal the decision. Appealing is easy, and most people who appeal win their case.
If you do not win your appeal at the first level, there are several stages to the appeals process. There are also many deadlines you must meet in order to appeal your health plans denial of payment. If your plan will not approve care that you need and have not yet gotten, and your “life, health, or ability to regain maximum function” is in jeopardy, you are entitled to a faster appeal. You will automatically get a fast appeal if your doctor requests one.
Before appealing you need to double check with your doctor to make sure that the service was billed correctly. Medicare uses a set of service codes and sometimes providers accidentally use the wrong codes when filling out paperwork, which can result in denial. Denial claims can sometimes be easily resolved by checking with your doctor that it was submitted with the correct codes. If it was submitted with the wrong code, ask your doctor to resubmit the claim with the correct code.
Here are the steps to follow for filing a standard appeal to a private Medicare health plan if they are denying payment for a service after you have received the service. Throughout the appeals process it is important to keep track of all notices you receive from the plan and to write down the names and times you speak with representatives from the plan.
The first step is to receive a denial notice. You must receive a written denial from the plan before you can start your appeal. Included in the denial notice will be information you need to start the appeals process.
You have 60 days from the date on the denial notice to file an appeal with the plan. In most cases, you will need to send a letter to the plan explaining why you needed the service. Ideally, you should also include a supporting statement from your doctor explaining why this service was medically necessary.
Once you appeal, the plan has 60 days to make a decision. If you do not hear back from the plan, you should call them.
If the plan does not make a decision in your favor, they must automatically forward your appeal on to the Independent Review Entity (IRE). The IRE is an independent group of doctors and other professionals that contract with Medicare to ensure that you receive quality care. The IRE has 60 days to respond.
the IRE upholds the plans denial, there are additional higher levels of appeal to which you can take your case. The next level is an Administrative Law Judge (ALJ), followed by the Medicare Appeals Council (MAC) and then Federal Court.
you are appealing at the ALJ level or higher, you may want to find an advocate or lawyer to help you.
—Marci
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Do you need individual counseling? Call the Medicare Rights Center's consumer hotline at 800-333-4114, between 9 a.m. and 5 p.m., Eastern Time, Monday through Friday. A Medicare counselor will be happy to answer your question.
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Health Tip of the Week
ch is National Colon Cancer Awareness Month. This year, approximately 13,000 people under the age of 50 will be diagnosed with colon cancer. Starting at age 50, both men and women who are at average risk for developing colorectal cancer should use one of the screening tests described below.
ever, if you experience any stomach discomfort, bleeding in your stool, or sudden weight loss, you should contact your doctor as soon as possible.
Here are some tips about screening for colon cancer from the Susan Cohan Kasdas Colon Cancer Foundation.
There are two types of screenings methods for colon cancer;
- tests that can find polyps (abnormal growths) and early cancer
- tests that mainly find cancer.
The tests that find early cancer and polyps are preferred if these tests are available to you. You should talk to your doctor about which test is best for you.
The tests that find polyps and cancer are:
- Flexible sigmoidoscopy *
- Colonoscopy
- Double contrast barium enema *
- CT colonography/virtual colonoscopy *
*Have one of these tests every 5 years and a colonoscopy every 10 years.
Tests that mainly find cancer are:
- Fecal occult blood test (every year)
- Fecal immunochemical test (every year)
- Stool DNA test (interval uncertain)
If test results are positive they should be followed up with a colonoscopy.
If you cannot afford a colonoscopy or it is not available near you, contact the Susan Cohan Kasdas Colon Cancer Foundation for assistance.
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Many adults do not get the vaccines they need. Parents typically ensure that their children have all their vaccinations, but a new report shows that 40,000 to 50,000 American adults die each year from diseases that could have been prevented with vaccines. The report was released jointly by the Trust for America’s Health, the Infectious Diseases Society of America and the Robert Wood Johnson Foundation.
The article in HealthDay News cites the pneumonia vaccine and the flu vaccine as examples of vaccines that adults are skipping. More than 30 percent of adults 65 and older in 36 states had not received the pneumonia vaccine. The CDC recommends the pneumonia vaccine for all adults age 65 and older. In 2008, the flu vaccine was only received by 36.1 percent of adults. Medicare Part B covers both the flu and pneumonia vaccines.
It is also cited in the article that only 2.1 percent of adults have had a tetanus, diphtheria and whopping cough vaccines. The tetanus vaccine is covered under Medicare Part B if you step on a rusty nail or have been exposed to the disease. Otherwise it should be covered under your Part D plan, but check with your plan to see how they cover vaccines.
Few adults also receive the vaccine boosters that are recommended for them. Dr. Marc Siegel, an associate professor of medicine at New York University, says that vaccines wear off and boosters are necessary. Tetanus shots only last 10 years.
The report listed many reasons as to why adults do not get their vaccines, which include: access to the vaccines since they are not required in most work places, lack of insurance and the ability to afford the vaccines, and fear that vaccines are not safe.
The report also listed some recommendations to encourage adults to get vaccines. These recommendations include: increasing coverage of vaccines by insurance companies, vaccine coverage for the uninsured and education about the safety of vaccines.
Dr. Siegel thinks that “…doctors should take time to make sure that adult patients are offered vaccines. In addition, something needs to be done to counter the fear many have of vaccines…”.
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