Friday, September 6, 2013

Denied Medicare Claims On The Rise

Many people are saying that denied Medicare claims are on the rise, but is it true? Consider this. Five years ago, a leading Washington source 1 [Note: Source is The Hill] reported that the American Medical Association (AMA), in comparing Medicare denial rates to those of seven large national insurance companies, determined Medicare was the most likely to deny a claim.

The Medicare denial rate, as reported, was just under 7 percent. Six months ago, a leading journal 2 [Note: Source is Kaiser Health News] reported that nearly 11 percent of Medicare claims were denied in 2010, the most recent year for which reliable figures are readily available.

All those figures indicate there was an increase of more than 50 percent in Medicare denied claims over the course of a few years leading to 2010 – and by all accounts the increase in denied claims has only continued since then. The result is that a rising number of people are learning that Medicare is not paying their healthcare providers and suppliers as expected, or that Medicare is denying their claims altogether.

Leading Causes of Denial of a Medicare Claim

In most cases, denial of a Medicare claim is the result of these causes:

Error by a doctor or other healthcare provider can occur in many forms. If a provider fails to furnish all the required information regarding a claim, Medicare is likely to deny the claim. Inaccuracy of any sort can also lead to denial. For example, if a provider mistakenly bills Medicare for the wrong service, the claim will be denied. Fortunately, simple errors by a provider can normally be corrected by resubmitting the claim with complete and correct information.

Failure to establish medical necessity
results in denial of many claims. Any service for which a claim is filed must be shown to be medically necessary, and, unfortunately, doctors sometimes fail to provide Medicare enough information to establish this. Establishing medical necessity is vital because if a claim is denied due to reasons concerning medical necessity, the only way to have the denial reversed is by requesting an appeal.

Receiving services from a provider not enrolled in Medicare is another leading cause of denied claims. It is important to ask whether a provider is enrolled in Medicare before accepting any services, and it is necessary to make sure information about Medicare enrollment is up to date. Many doctors have chosen to leave Medicare in recent years, and patients need to keep informed about their Medicare options.
Other errors include those made by contractors who process Medicare claims and, in the case of people who have other insurance along with Medicare, mix-ups over whether Medicare is the primary or secondary payer. Sometimes Medicare may mistakenly be listed as the secondary payer when it is in fact the primary payer. As a result, Medicare may deny a claim because it has determined that another insurer needs to pay its share first. Errors of this type can normally be corrected by calling 1-800-MEDICARE.

What is the best way to ensure your Medicare claim won't being denied?

Start by being attentive to the causes of denial that we've just discussed. Taking every precaution to ensure complete and accurate information is submitted will go a long way toward preventing denial of a claim. Don't be hesitant to remind your doctor how important it is to be precise and complete in providing documentation to support your claim and to establish medical necessity. Never take shortcuts in determining whether a provider is enrolled in Medicare. And, if you have other health insurance along with Medicare, make sure you know which insurer is the primary payer every time a Medicare claim is submitted on your behalf. If you need help determining whether Medicare is a primary or secondary payer, call the Medicare Coordination of Health Benefits Contractor for assistance at 1-800-999-1118.

Many people have no idea their Medicare claims have been denied until they look over their Medicare Summary Notices (MSNs). MSNs are the statements Medicare recipients receive quarterly to show charges billed to Medicare for their healthcare services, and payments approved and made by Medicare.

To head off any potential problems before they become serious, you can track your Medicare claims well in advance of receiving your MSN. Claims can normally be tracked with 24 hours of processing at

If you have a Medicare claim that has already been denied, you or your medical provider can file an appeal. You can easily start the appeal process by following instructions on the back of your Medicare Summary Notice.

If you have evidence to support your claim, there is a good chance your denial will be reversed. Figures for 2010 show that two fifths of Medicare Part A appeals and over half of Part B appeals were successful. More than 50 percent of appeals to Medicare Part C and Medicare Part D plans were also successful.3 [Note: Source is Reuters]

The vast majority of people whose Medicare claims are denied do not even seek reversal. Only about 2 percent of Medicare denials in 2010 were appealed.4 [Note: Source is Kaiser Health News] Given the fact that simple errors seem to be responsible for much of the increase in Medicare denials in recent years,

No comments:

Post a Comment