Medicare claim denial may take any Medicare beneficiary by surprise. Perhaps you, too, have been shocked to find that Medicare denied a claim that you were sure would be paid. Medicare offers broad, comprehensive medical and hospital coverage for eligible beneficiaries and can pay for most medically necessary services. A little known Medicare secret is that Medicare's coverage guidelines are far more flexible and far less restrictive than those of most private insurance companies. However, sometimes Medicare claims may deny for seemingly incomprehensible reasons. The chances are that if you have experienced a Medicare claim denial, you have fallen prey to one of the 5 basic reasons for Medicare claim denial. This article will tell you what they are, and what you can do to see that Medicare reverses its denial and pays on your claims.
The number one reason for claim denial in the Medicare system is probably due to error in either the way the claim is submitted or in the information provided. This often occurs when the provider omits information needed by Medicare to process the claim. In some cases, this may lead Medicare to think that the services are not medically necessary. In other cases, a provider may bill Medicare for the wrong service. When these situations arise, it is necessary to advise the provider to either get Medicare the information it needs to process the claim, or advise the provider to resubmit the claim for the service you received. A common example of provider error is when a beneficiary receives a covered pap and pelvic exam, but the doctor office bills these services as an office visit. In such a case, Medicare will deny the claim. This is easily corrected by the doctor office resubmitting the claim and billing Medicare for the exact services received.
Medical Necessity Denials
This is a specialized form of provider error. The average Medicare beneficiary may experience this when a medically necessary service, such as a lab service, is denied for no apparent reason. In fact, the beneficiary, you perhaps, may have received this service many times in the past with no problem. What often happens is that the provider submits the claim with insufficient information to show that the service is medically necessary. In this case, you must not resubmit the claim. Medicare requires that when a claim is denied for reasons of medical necessity that you appeal the claim. In Medicare language, this is called a redetermination. You can do this yourself, or the provider who submitted the claim can do this on your behalf. This is not complicated. You simply follow the instructions on the last page of the Medicare Summary Notice (this is an explanation of benefits in Medicare). You would need to circle the items you wish to appeal, sign the Medicare Summary Notice, and fill in the blanks for telephone number, Medicare number, and signature, and then return the Summary Notice to the address give on the last page. Medicare also recommends that you send any relevant information from your medical records with your appeal that would help show that the services you received are medically necessary.
Provider not Enrolled in Medicare
Another common reason for Medicare claim denial is that you receive services from a health care provider who is not enrolled in the Medicare program. In order for Medicare to pay on claims or reimburse you for charges, your doctors, hospitals, and other providers must be in the Medicare program. In this case, there really is no recourse other than to be sure that in the future you receive medical services from providers enrolled in Medicare.
Medicare Secondary Payer (MSP)
Medicare secondary payer, or MSP, errors can cause a great deal of confusion, but they are among the easiest to correct. This sort of error occurs when Medicare records indicate incorrectly that Medicare should be the secondary pay on claims instead of the primary. Thus, when a provider submits a claim to Medicare, Medicare denies because it thinks that there is some other insurer who should be paying first on the claim.
There are a number of different reasons why this occurs, but what you should do as soon as you find out is call 1-800-MEDICARE (1-800-633-4227). In some cases, a representative will be able to correct the problem by updating the records. In other situations, you must speak with the Medicare Coordination of Benefits Contractor (1-800-999-1118). Rest assured that as soon as the records are updated, Medicare will be able to reprocess all claims as primary payer. In most cases, your providers must resubmit their claims following Medicare's correction.
Medicare claims also deny due to contractor error. A Medicare contractor is a company who has a contract with the Federal government to process claims for Medicare. When you receive doctor and hospital services, your providers send their claims (usually electronically) to the specific "contractor" appointed to process and pay on claims for your state of residence. Sometimes, due to clerical error, the Medicare contractor denies a claim. Normally, when a claim denies due contractor error, it is necessary to notify the contractor and request an adjustment of the claim. The correct way to do this is either to call 1-800-MEDICARE and ask for help or to have your provider contact the contractor about the claim denial.
Medicare claim denials may cause both beneficiaries and caregivers confusion, stress and anxiety. However, it important to understand that Medicare can and does pay on most medically necessary services, and that when a claim denial occurs it is extremely important to call 1-800-MEDICARE (1-800-633-4227) as soon as you find out so that a representative can examine the claim and discuss your options. In many cases, these claim denials can be reversed and the claims either reprocessed or adjusted. In all cases, Medicare regulations allow beneficiaries the right to appeal any decision about their claims. In order to know the best course of action for you, it is crucial to contact Medicare as soon as possible following your discovery of claim denial.