Have You Had a Medicare Claim Denied? Here’s Help with the Medicare Appeals Process.

Medicare Appeals ProcessOn average, seniors are each taking 15 – 18 different prescribed medications, so Medicare coverage of these medicines is often extremely important. And with the standard pricetag of more than $11,000 on a yearly basis for the most common medicines prescribed for the elderly, it could be devastating when Medicare suddenly declines coverage. And yet, that’s taking place a lot more frequently as Medicare plans are increasingly imposing coverage limitations on elderly people – generally outside of affirmation from the Centers for Medicare & Medicaid Services.

Since the Medicare appeals process for denied coverage can be so difficult, regrettably, a great many seniors just accept the denial – at either an outrageously high financial impact, and also at great risk to their well-being when necessary prescription drugs are stopped because of lack of Medicare insurance coverage. As outlined by David Lipschutz, senior policy attorney at the Center for Medicare Advocacy, “A lot of people fall through the cracks. They simply don’t know what to do. Or they try to go through the process, and it’s complicated and time-consuming and they just give up.”

Even though a number of prescription drugs must be covered by Medicare across the board (medications for HIV/AIDS, depression, cancer, and seizures, as well as others), there’s a gray area by which prescription drugs are covered for other conditions – and preapproval is usually needed, or patients are given the requirements that less expensive options need to be used first (also referred to as step therapy). Denials usually occur because of a consequence of neglecting to fulfill these requirements.

So, exactly what can a senior do in order to receive the drug coverage to which they’re entitled? There are a few key steps:

  • First, ask for a formal coverage determination from the senior’s Medicare drug plan. Information on submitting this specific request can be found by clicking here.
  • Once insurance coverage is established, there will be 5 levels in the Medicare appeals process, specified here.
  • Keep detailed documentation throughout each and every phase of the process. To get more help, the Medicare Rights Center can assist. You can reach them at 800-333-4114.

Bear in mind it’s important to be persistent. Often, higher levels of appeals are approved even though preliminary steps generate disheartening results. Call Home Sweet Home In-Home Care, providers of expert Kalamazoo senior care, for additional recommendations and hands-on support for older adults. We can provide resources to help older persons as well as their families advocate for themselves, as well as professional in-home care services to ensure that medicines are taken exactly as prescribed, that prescription medication refills are handled, and much more. Call us at (269) 849-9252 and discover how you can keep your older loved one safe and flourishing!

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