Who Pays if Medicare Denies a Claim?

Finding out that Medicare has denied a claim for medical services can be stressful and confusing. As a Medicare beneficiary, you want to receive the health services you need. But you don’t want to be stuck with a big bill if Medicare refuses to pay. This article will explain what happens when Medicare denies a claim, who is responsible for payment, and what you can do to appeal the decision.

What is a Medicare Claim?

First, it helps to understand what a Medicare claim is.

A claim is a request for payment that your doctor or other health care provider submits to Medicare after you get medical services. The claim includes details like:

• Your personal information (name, Medicare number, date of birth, etc.)

• Details about your diagnosis and the services you received

• The date(s) the services were provided

• The charges for the services

• Other billing codes and information

Your provider is responsible for submitting the claim to Medicare. Medicare then processes the claim and decides whether to pay it.

Reasons Why Medicare May Deny a Claim

There are a few common reasons why Medicare may deny a claim:

• Missing information – The claim form was incomplete, had errors, or was missing codes or required information.

• Not medically necessary – Medicare decided the medical services were not necessary for your condition.

• Too frequent/too many services – Medicare felt the number of services you got exceeded what was considered reasonable or necessary.

• Non-covered services – The services are not covered by Medicare at all. For example, dental cleanings are not covered.

• No prior authorization – Some services require prior approval from Medicare before they will pay. If this was not obtained, the claim may be denied.

• Doesn’t meet coverage criteria – In some cases, Medicare has specific guidelines around when they will pay for certain services. If those criteria are not met, Medicare can deny the claim.

• Provider not eligible – If the provider is not registered and eligible to bill Medicare, the claims will be denied.

• Local coverage determination – Some Medicare contractors establish local coverage rules. If those rules are not met, a claim may be denied.

Who Pays if Medicare Denies the Claim?

If Medicare denies the claim, then who is responsible for paying depends on whether your provider submits the claim or not.

There are two options:

Option 1: Provider submits the Medicare claim

This is the most common scenario. Even if the provider believes Medicare may not pay, they will still submit the claim in most cases.

• You will be notified by Medicare if the claim is denied. This will come in the form of a Medicare Summary Notice (MSN).

• If Medicare denies the claim, you are responsible for payment since services were provided.

• However, you have the right to appeal the decision. The appeals process will be explained on the MSN.

• If your appeal is successful and Medicare ends up paying the claim, then your provider will reimburse you for any payments you already made (except copays and deductibles).

Option 2: Provider does not submit a Medicare claim

In some cases, your provider may give you notice up front that they do not believe Medicare will pay for a certain service. They may ask you to pay for it yourself without billing Medicare.

• If you agree and the provider never submits a claim, then you will be fully responsible for paying the provider directly.

• Medicare will have no record of the services or charges.

• With no claim submitted, you have no ability to appeal to Medicare for payment.

• Be sure you understand and agree before choosing this option, since you lose the right to appeal.

The Medicare Denial Notice

If Medicare denies a claim, they are required to provide a written notice explaining the specific reason for the denial. This notice gives you important information about your appeal rights.

Look for a section called “The Medicare Summary Notice” (MSN). This will provide details on the denied claim such as:

• Date of service
• Amount billed
• Amount paid (will show $0 if denied)
• Reason for denial
• Instructions for filing an appeal

Be sure to check your MSNs closely for any denied claims and follow up promptly. Medicare limits how long you have to file an appeal after getting a denial notice.

Appealing a Medicare Denial

As the Medicare beneficiary, you have the right to appeal if a claim is denied. The appeals process has strict deadlines, so it’s important to act quickly. Here is an overview of the Medicare appeals process:

Step 1: Redetermination

This is the first appeal filed with the Medicare administrative contractor that processed the original claim. You’ll want to submit evidence to support your case, like a letter from your doctor.

Step 2: Reconsideration

If the redetermination fails, you can request a reconsideration. This is reviewed by a different Medicare contractor than the original one.

Step 3: Hearing before an ALJ

If you disagree with the reconsideration, you can request a hearing with an Administrative Law Judge (ALJ).

Step 4: Medicare Appeals Council Review

If the ALJ denies your appeal, the next step is to request a review by the Medicare Appeals Council.

Step 5: Federal District Court

This is the final level of appeal, in which you take your case to federal district court.

There are also expedited appeals for urgent cases, like an appeal for an ongoing service.

Where to Get Help with Denied Claims

Navigating the Medicare appeals process can be complicated. Here are some resources that can provide assistance:

• 1-800 MEDICARE – Call Medicare directly to get information about your denial notice or help initiating an appeal.

• State Health Insurance Assistance Program (SHIP) – Local counselors provide free Medicare help and can assist with appeals.

• Medicare Rights Center – Experts can help you understand denial reasons and the appeals process.

• Eldercare Locator – Get connected to your local Area Agency on Aging for Medicare counseling.

• AARP – If you’re an AARP member, you can speak with an AARP Medicare expert.

• Medicare Advantage Plans – If you have a Medicare Advantage Plan, contact them for help appealing.

• Attorneys – For complex cases, consulting a Medicare attorney may be helpful.

Having a claim denied by Medicare can be upsetting and confusing. But with persistence and help, many denials can be successfully appealed. So don’t give up! Reach out to an expert to go over your options.

Key Takeaways

• It’s your health provider who submits claims to Medicare, not you.

• Common reasons for Medicare claim denials include missing information, not medically necessary, too many services, non-covered services, and not meeting coverage criteria.

• If your provider submits a claim that’s denied, you are responsible for payment but can appeal to Medicare.

• If your provider never submits a claim, you must pay them directly and cannot appeal.

• A Medicare Summary Notice will explain denials and appeal rights.

• You can get help appealing from 1-800-MEDICARE, your State Health Insurance Assistance Program, Medicare Rights Center, Eldercare Locator, and Medicare Advantage Plans.