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Appealing a Denied Medicare Claim May Be Worth the Effort

November 11th, 2012 by Deb Wilson

Interesting statistics from The Wall Street Journal:

In 2010

  • 14.1 millions hospital (Part A) Medicare claims were initially denied, however, only 295,000 were appealed.  Of those 295,000 claims appealed there was a 40% success rate in obtaining payment as a result of an appeal request.
  • 93 million doctor visit and other medical services (Part B) Medicare claims were denied with 2.4 million subsequently appealed for a 53% success rate in overturning the denial.

If Medicare Tells You ‘No’

With those odds, anyone whose claim is denied should consider filing an appeal.  Medicare recipients receive a Medicare Summary Notice each time charges for a medical service are submitted to Medicare for payment.  The Summary Notice indicates whether, and how much, Medicare will pay the hospital, doctor or other healthcare provider for the charges and whether the Medicare “beneficiary” must pay any portion of the charges.  The Summary Notice also contains information on the Medicare beneficiary’s right to file an appeal for any charges that are denied by Medicare.  Unfortunately the language about the appeal right on the Summary Notice can be hard to understand and appear to be a difficult process.

The Wall Street Journal does a good job of breaking down appeal rights and the appeal process into a more readable format and provides information on where to find help in filing an appeal.  Important information to file away for a time when you may feel that your claim has been unfairly denied.


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