If you're on Medicare, it's important to know that you have rights and that there are procedures in place for you to make your case if necessary. Medicare appeals and grievances are two avenues you can use depending on the situation. Medicare appeals are used if you disagree with a coverage or payment decision by Medicare or your Medicare plan. Medicare grievances are used when you have concerns about the quality of care or other services you get from a Medicare provider.
An appeal is the action you can take if you disagree with a coverage or payment decision by Medicare or your Medicare plan. Some examples: You can appeal if Medicare or your plan denies:
A request for a health care service, supply, item, or drug you think Medicare should cover
A request for payment of a health care service, supply, item, or drug you already got
A request to change the amount you must pay for a health care service, supply, item, or drug
The appeals process differs between original Medicare and Medicare Advantage plans. For Medicare's guide on the appeals process, click here to visit the Medicare appeals reference page.
Medicare Grievances (Complaints)
A Medicare grievance is basically a complaint about the quality of care or other services you get from a Medicare provider. You can file a complaint about:
A doctor, hospital, or provider
Your health or drug plan
Quality of your care
Your dialysis or kidney transplant care
Durable medical equipment
For Medicare's guide on the grievance process, click here to visit the Medicare grievances reference page.
My Personal Experience
Not long after we were on Medicare ourselves, I had the opportunity to file an appeal to my wife's plan. She had gone to see her primary care provider, which should have been a $0 copay. On that particular visit, she did not see the doctor but instead was seen by the physician's assistant (PA). We had no complaint with the care provided and agreed that the PA was the most expediant way to be seen on short notice. However, when we were billed for the visit, instead of the expected $0 copay, we were billed the copay for a specialist, $35. I logged on to the carrier's member portal, went to the claims section, found the mechanism for filing an appeal online and did so. I basically told them that the PA could not possibly be a specialist because she was not a doctor to begin with! They agreed with me. The charge was reversed within 30 days or so of filing the appeal.
Medicare Appeals and Grievances Work - Use Them!
Medicare appeals and grievances work, especially with Medicare Advantage plans, because the outcomes can affect a plan's star ratings. Medicare Advantage plans tend to be protective of their star ratings for good reason: star ratings is the only public measure of plan member satisfaction with the plan. Another good reason to use appeals is that over 70% of all Medicare Advantage plan decisions are overturned on appeal. Here's a quote from a report by the OIG (Office of Inspector General):
What OIG Found. When beneficiaries and providers appealed preauthorization and payment denials, Medicare Advantage Organizations (MAOs) overturned 75 percent of their own denials during 2014–16, overturning approximately 216,000 denials each year. During the same period, independent reviewers at higher levels of the appeals process overturned additional denials in favor of beneficiaries and providers. The high number of overturned denials raises concerns that some Medicare Advantage beneficiaries and providers were initially denied services and payments that should have been provided.
Bottom line? File the appeal! As always, if you need assistance with any of the topics in this post, please feel free to contact me.