What You Need to Know Before Choosing or Switching Medicare Part D Programs

Bad Part D Choices Can Lead to Extra Expenses for Seniors on Medicare

Tis the season for anyone on Medicare to decide if they want to make any changes to their Medicare Part D plan beginning with the New Year and the ads are everywhere.

There are ads from pharmacies, offering assistance choosing a Part D plan, and ads from Part D providers encouraging people to choose their option.

Having observed some of these plans in action last spring as they came into effect, I have a few words of caution for anyone selecting or changing their Medicare Part D plan. Part D is the Medicare prescription drug program that has been highly touted as a boon for those on Medicare, but in reality is not as good as it could be.

In Illinois, many people who are now covered by Medicare Part D were once covered by an Illinois state program called Circuit Breaker. The Circuit Breaker program helped those low-income seniors without a Medicare supplement insurance to get prescription drugs at a reasonable cost. Sure, there were co-pays, but most were $10 to $15.

When the federal government began offering the Medicare Part D option, p

How to Appeal a Health Insurance Denial

Battling a health insurer when it refuses to cover certain treatments can be aggravating and time-consuming. But if you choose to appeal a coverage denial, there are several strategies that can bolster your case.

Some health-coverage problems — such as when your doctor enters a wrong code on a claim form — can be resolved with a phone call. But other issues can be more difficult, because they center on complex medical questions like whether a certain cancer treatment is appropriate for you.

First, figure out what led to the denial of coverage and learn your insurer’s procedure for appeals. When you call your health plan to get the information, take notes and get names. If the problem can’t be readily resolved, you should ask the insurer for some key documents to reconstruct what led to the rejection.

You will need the denial letter. You should also get a copy of your plan’s full benefits language, sometimes called the “Evidence of Coverage,” as well as the detailed guidelines that explain what the company considers medically necessary. Some companies, such as Cigna Corp. and Aetna Inc., post their medical policies online.

Top 5 Reasons for Medicare Claim Denial

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.

Provider Error

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

Medicare part B covered services - CPTs

Medicare Part B Covered Preventive Services

•Bone Mass Measurement for certain people who are at risk of losing bone mass
•Colorectal Cancer Screening
1.Fecal Occult Blood Test once every 12 months
2.Flexible Sigmoidoscopy once every 48 months
3.Colonoscopy once every 24 months for people at high risk for colon cancer
4.Barium Enema (physician can subtitute for sigmoidoscopy or colonoscopy
•Diabetes Services for people who have diabetes (insulin users and non-users)
1 Coverage for glucose monitors, test strips, and lancets (coverage through DMERC)
2.Diabetes self-management training
•Mammography Screening for all women over age 40, once every 12 months
•Pap Smear and Pelvic Examination for all women, once every 36 months (beginning July 1, 2001, once every 24 months) and for women with high risk for cervical cancer or previous abnormal Pap Smear , once every 12 months
•Prostate Cancer Screening for men aged 50 and over;
1.Digital Rectal Examination every 12 months
2.Prostate Specific Antigen (PSA) Test once every 12 months
•Medical Nutrition Therapy (MNT) is a covered benefit effective January 1, 2002, for patients with diabetes or renal disease.
•Glaucoma Screening is a covered benefit effective January 1, 2002, for individuals with diabetes, a family history of glaucoma, or others determined to be at "high risk" for glaucoma.
•Vaccinations
1.Flu vaccination once a year in the fall and winter
2.Pneumonia vaccination (one lifetime)
3.Hepatitis B vaccination for people with medium to high risk for hepatitis

Non-Covered Services

What is Medicare

What Is Medicare?

The Medicare program is a federal health insurance program for people 65 years of age or older and certain disabled people. It is run by the Centers for Medicare and Medicaid Services (CMS), a division of the U.S. Department of Health and Human Services. Social Security Administration offices across the country take applications for Medicare and provide general information about the program. Independent insurance carriers throughout the United States administer the claims processing.

There are two parts of the Medicare Program. Hospital insurance is known as Part A and medical insurance is known as Part B.

Does Your Patient Have Medicare?

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