By
one count, nearly one-third of Medicare Advantage plan enrollees say they were
denied coverage for treatment by their plans. Such denials of coverage can be
enraging or even life-threatening. However, there is an appeal process to
resolve these conflicts.
If you (or a loved one) have a
Medicare Advantage plan, then it is important to be prepared should the plan
itself overrule your doctor and deny you coverage. That certainly would be an
unfortunate turn of events! Fortunately, you can seek to overrule coverage
denied by your Medicare Advantage plan, but you must know how.
While you can be denied
coverage, it is important to remember that the Medicare Advantage plan is not
the final arbiter and you can appeal their decision. This is an important right
built into the very structure of Medicare. A timely article in ElderLawAnswers.com titled “Appealing Medicare Advantage Plan Decisions”
provided some insights into this process.
Did you know that above every
Medicare plan is the judicial oversight of an Administrative Law Judge (ALJ)?
When the plan makes an adverse coverage decision, first you should appeal to
their better judgment. If you are unsuccessful, then you can go over their
heads and appeal to the ALJ.
But wait, there is more. If you
are unsuccessful before the ALJ, then go even higher to the Medicare Appeals
Council (MAC). Be aware, however, that at this level the process becomes a
matter of litigation and all that entails time and money. Nevertheless,
litigation is sometimes a necessary evil to pursue necessary care (and
justice).
You may never need to challenge
a denial of coverage. In case you do, however, it is best to be prepared and
that means being well-informed regarding your rights.
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Reference: ElderLawAnswers.com
(last modified September 26, 2013) “Appealing Medicare Advantage Plan Decisions”