What If Medicare Denies Your Parent's Medical Services?

Posted on: 9 May 2016

When your elderly parent needs a medical care service and Medicare refuses to pay for it, you can file an appeal to ask for a reconsideration from Medicare. Appealing a denial can be challenging, but it is possible to have the decision overturned. If you are thinking of filing an appeal, here are some steps you can take to improve your odds of success.

Review the Organization Determination Notice

When Medicare denies a service, the agency sends an Organization Determination notice to explain why. The notice can help you devise a plan to appeal the decision from the agency. 

If you do not understand the reasoning for the denial, contact Medicare directly and ask for clarification. The timeframe to appeal the decision is small, so act immediately. 

Write an Appeal Letter

Written documentation is an important part of the appeals process, and you can start it off by writing an appeal letter explaining why your parent's medical service needs to be approved. Use the Organization Determination notice as your guide. Address each issue that is presented in the notice in your letter. 

For instance, if the notice states that the medical service was not medically necessary, explain why it is and provide contact information for medical care providers who can support your assertion. As an added measure, obtain statements from your parent's medical care providers stating why the procedure is necessary.

Before mailing the appeal letter to the address on the Organization Determination notice, make a copy of the notice and your letter. Retain those copies for your personal records. 

Request Another Reconsideration

In the event that Medicare continues to deny your parent's service, you can request another reconsideration. The reconsideration is conducted by an independent organization. The organization might require additional information from you, your parent, and his or her medical care providers. 

If the organization sides with Medicare, there are two additional levels of appeals you can follow. The next level involves an administrative law judge. The hearings are usually not held in person, but by telephone. In some instances, a hearing can be held in person, but there has to be a good reason for it. 

If a hearing is scheduled, it will be conducted in a conference room instead of a courtroom. Your parent's attorney has the right to call in witnesses to testify. 

Consult with an attorney experienced in elder law (such as Cormac McEnery) to work on a strategy to overturn the decision of Medicare.