Medicare Denied Your Procedure — Now What? – NerdWallet

Medicare Advantage plans denied or partially denied 2 million requests for prior authorization for medical services in 2021, according to a 2023 analysis from KFF, a health policy nonprofit. Prior authorization is often required for more expensive services, such as chemotherapy or stays in a skilled nursing facility.

Only 11% of those denials were appealed, even though a large majority of appeals led to a partial or total reversal of the decision.

Denials can also happen after a procedure. “Last year, we got a call from a woman who got a knee replacement without prior authorization,” says Diane Omdahl, president and co-founder of 65 Incorporated, which offers Medicare guidance. “It was denied after the fact, and she was looking at a $62,000 bill.”

Whether you’re seeking to continue services you’re already receiving or trying to get approval for a future operation, here’s how to tackle a “no” from your Medicare provider.

If your Medicare plan denies your procedure or prior authorization, you’ll get a letter with the information you need to appeal it. This includes how much time you have to take action, which varies based on the kind of denial.

“I’m amazed how many people get a denial but they didn’t read the letter,” Omdahl says. “They do tell you what your next steps are.”

If you’re using Original Medicare benefits — and you’re in the hospital, for instance, or getting services from a home health agency — you’ll get a Notice of Medicare Non-Coverage letting you know your services will be ending. The notice will include instructions for a fast appeal.

If you have a Medicare Advantage plan, you’ll get a Notice of Denial of Medical Coverage (or Payment), which will include information on the standard and expedited appeals processes.

Communications from your Medicare provider should clearly lay out the deadlines for filing an appeal.

If you need services that your insurer thinks should end, you can push for an expedited decision — within 72 hours for a health plan appeal or 24 hours for a prescription drug appeal. “Fast appeals are used to keep services in place,” says Kathleen Holt, an attorney and associate director of the Center for Medicare Advocacy.

Deadlines for fast appeals vary by setting and health plan, but you may be asked to file by a particular day and time. Take note: Medicare isn’t just a Monday-to-Friday operation — Saturdays and Sundays count.

“This is a 24/7 business, and if they say you have until noon the next day, they mean the next day,” Holt says. “They have time- and date-stamped voicemails, so the clock is ticking. If you’re trying to do a fast appeal but you call at three in the morning on a Saturday morning, it’s going to date stamp.”

Your doctor is probably best equipped to make an argument for why you might need a procedure or continued services. They can speak to why it’s medically necessary, why it’s reasonable to do it and why it has to be done in a particular way.

“The doctor and the facility have a vested interest in seeing that this goes through, too, because they don’t want payment to be denied,” Omdahl says.

There’s a difference between an appeal and a grievance. A grievance is a complaint about a plan process, while an appeal is the process through which you challenge a Medicare coverage decision.

The Center for Medicare Advocacy has heard from people who missed their appeal deadline because they called their Medicare Advantage provider and a representative asked if they wanted to file a grievance — and they didn’t understand the difference, Holt says.

“That, to me, is dirty pool,” Holt says. “If someone calls you and says, ‘I’m having trouble with my claim getting paid,’ don’t divert them into, ‘OK, so you want to file a grievance?’ That’s not the right procedure at all.”

Keep a record of what you’ve done as you work on your appeal, Omdahl says. At each step, document the date and time, the name of anyone you spoke with and any details of your conversation. If you have to escalate your appeal, it’s helpful to be able to reference the steps you’ve taken.

Each state has a State Health Insurance Assistance Program, or SHIP, that offers free Medicare guidance. You can find your state SHIP at shiphelp.org.