In the Medicare system – like most other insurance companies – have an appeal process for denial of payment of claims…
All those various insurance providers do not want pts to know but NOTHING – in regards to denial of claims is in CONCRETE… they all have appeal processes… they don’t have to tell you about the process – UNLESS YOU ASK.. then they are required to provide you their appeal process in writing.. .today.. that might be a web page.
A Administrative Law Judge (ALJ) hearing is the last/final appeal in the Medicare system. This is normally handled by a retired judge or attorney. The pt will present “their case” as to why their denied claim should have been paid for by Medicare/Medicaid.
Here is the CMS website describing the appeal process. https://www.medicare.gov/claims-and-appeals/file-an-appeal/appeals.html
Generally speaking, >50% of people who appeal their denied claims to this level will get their claim APPROVED. Often the ALJ hearing officer may not have an extensive medical background and will attempt to apply “logic” to what is medically necessary for the pt and how approving the requested service would help a pt’s quality of life from deteriorating further or improving their quality of life.
Typically, these hearings are pretty INFORMAL and the ALJ will have the written denial determination from the carrier and it is up to the pt to demonstrate how the product/service that is requested is basically medically necessary and within the guidelines of what Medicare/Medicaid should be providing.
The only cost to the pt in dealing with the hearing is traveling to where ever the in person hearing is held. If that is too far a distance for a pt to travel, they may be able to take advantage of a Video-Teleconferencing center which would be more convenient.
Sometimes, the fact that the pt requests a in-person ALJ hearing… the carrier will reconsider their denial and reverse their earlier denial and approve the claim, because they know that they will probably get their denial overturned and will end up paying for it anyway.
Filed under: General Problems
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