When patients or doctors
disagree with Medicare's reimbursement decisions, they have the
right to appeal and ask that the program provide coverage for
something it had rejected.
Whether patients must reimburse their doctors
during the appeals process for claims that Medicare rejects primarily
depends on whether the patients signed an Advance Beneficiary
Notice before the appointment. Doctors are supposed to give patients
those notices when they are going to have an appointment or service
that the doctors do not expect Medicare to cover. When patients
do not sign an Advance Beneficiary Notice before an appointment,
they are not responsible for charges not covered by Medicare.
After submitting a bill for a doctor's appointment
or other health care costs incurred outside of a hospital, Medicare
beneficiaries and their providers receive a document that lists
the portion of charges that will be covered. Patients or doctors
can appeal when a service is not covered. When patients are the
ones filing the appeal, Medicare encourages them to get a letter
from their doctor explaining why the health care service was medically
If a patient or doctor continues to push an appeal
through the system after the first review does not result in an
increased payment, he or she may be able to request a hearing
with an administrative law judge. Under a 2000 law, Congress mandated
a 90-day processing time for these cases, but key provisions of
that law have not gone into effect. Scully told the House in April
2003 that it takes about 330 days to complete the average Medicare
hearing. Some appeals for amounts over $1,000 continue beyond
this stage and are eventually resolved in federal court.
The steps for non-urgent appeals of decisions
on Medicare Part A coverage, such as costs associated with hospital
stays, are similar to the steps for outpatient services. However,
there are fewer levels of appeals, so they advance more quickly
to the administrative law judge stage.
Medicare beneficiaries covered by private Medicare
+ Choice plans can also appeal decisions made on their coverage.
When the plans do not find in the beneficiaries' favor, their
decisions are reviewed by an independent organization that works
for Medicare and not for the private plan.
Whether hospitalized patients are in Medicare
+ Choice or traditional Medicare, they can file an urgent appeal
if they are told Medicare will no longer cover their hospital
stay. If that appeal is filed within approximately 24 hours, the
reviewing doctors will issue a ruling by the end of the next business
Patients can request a review of that initial
appeal decision, and that second appeal can take up to three business
days. If the initial appeal request was filed on time, patients
are not charged for their hospital stay while their appeal is
being reviewed, even if their request is eventually rejected.
According to the Medicare Rights Center, the majority
of people who file appeals eventually are successful in receiving
additional Medicare coverage.
-- By Karyn Schwartz, Online NewsHour