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