How best to appeal Medicare Advantage plan denial?
May 5, 2019 6:12 PM Subscribe
My mom is stuck in skilled nursing recovering from a fall and her Medicare Advantage plan will not pay for it. How do I write an effective appeal?
I asked this question in March (thank you to all who took the time to answer!). Now I am looking for advice on filing an appeal with her Medicare Advantage plan appeal and/or suggestions on where to look for advice, tips, help, anything.
I don't think I mentioned this in the last question, but my mom has a Medicare advantage PPO with Anthem, so I am dealing with Anthem rather than Medicare directly.
Here is the current situation:
1) My mom is still in a skilled nursing facility. I was able to get her transferred from skilled nursing facility #1 (SNF #1), where she was very depressed and unable to participate in PT to skilled nursing facility #2 (SNF #2) on 3/26/19. She is now on antidepressents, more or less like herself, and only 15 minutes from me.
2) Anthem did end up paying for her entire stay at SNF #1. The staff there would file for an extension every few days and it would be granted.
3) The first week of April, the staff at SNF #2 contacted me that Anthem had denied their claim for the last two weeks of March. Apparently, SNF #1 had reclassified my mom as a custodial patient rather than short-term. Not that this helps me in anyway, but I got the impression from SNF #1 that they were irritated with my mom for being unable to do PT and were looking for a quick way to get rid of her.
4) Staff at SNF #2 told me to call Anthem to inquire about an appeal. They actually gave me a number that was only for providers. I think it was the office where a doctor reviews claims. Anyway, the person who answered took the time to explain why they denied the claim. According to the notes, my mom showed an overall decline from 3/26 - 3/31. Specifically, the PT would come in and say "Would you like to do some PT?" and my mom would say no. I don't plan to appeal the denial for this period.
5) The second week of April, I met with the case worker and head of PT at SNF #2 to come up with a plan to get my mom reclassified as "short term patient who is making progress." PT and OT 6 days a week for 2 weeks and them SNF #2 would submit a new request for skilled nursing coverage from Anthem. I explained to my mom at this point what was happening and she has been participating in PT to the best of her ability. She has made remarkable progress. She can walk 20 steps now with a walker and assistance.
6) Anthem denied the second claim. SNF #2 advised me again to contact Anthem about an appeal. I spoke to someone in member services and was instructed to mail letter of appeal.
My question: What should I put in the letter? Information from her recent PT notes? Are there phrases that are particularly effective? Honestly, I'm overwhelmed and confused by all of this and can't tell if websites offering help are scams or what.
Thank you very much in advance.
I asked this question in March (thank you to all who took the time to answer!). Now I am looking for advice on filing an appeal with her Medicare Advantage plan appeal and/or suggestions on where to look for advice, tips, help, anything.
I don't think I mentioned this in the last question, but my mom has a Medicare advantage PPO with Anthem, so I am dealing with Anthem rather than Medicare directly.
Here is the current situation:
1) My mom is still in a skilled nursing facility. I was able to get her transferred from skilled nursing facility #1 (SNF #1), where she was very depressed and unable to participate in PT to skilled nursing facility #2 (SNF #2) on 3/26/19. She is now on antidepressents, more or less like herself, and only 15 minutes from me.
2) Anthem did end up paying for her entire stay at SNF #1. The staff there would file for an extension every few days and it would be granted.
3) The first week of April, the staff at SNF #2 contacted me that Anthem had denied their claim for the last two weeks of March. Apparently, SNF #1 had reclassified my mom as a custodial patient rather than short-term. Not that this helps me in anyway, but I got the impression from SNF #1 that they were irritated with my mom for being unable to do PT and were looking for a quick way to get rid of her.
4) Staff at SNF #2 told me to call Anthem to inquire about an appeal. They actually gave me a number that was only for providers. I think it was the office where a doctor reviews claims. Anyway, the person who answered took the time to explain why they denied the claim. According to the notes, my mom showed an overall decline from 3/26 - 3/31. Specifically, the PT would come in and say "Would you like to do some PT?" and my mom would say no. I don't plan to appeal the denial for this period.
5) The second week of April, I met with the case worker and head of PT at SNF #2 to come up with a plan to get my mom reclassified as "short term patient who is making progress." PT and OT 6 days a week for 2 weeks and them SNF #2 would submit a new request for skilled nursing coverage from Anthem. I explained to my mom at this point what was happening and she has been participating in PT to the best of her ability. She has made remarkable progress. She can walk 20 steps now with a walker and assistance.
6) Anthem denied the second claim. SNF #2 advised me again to contact Anthem about an appeal. I spoke to someone in member services and was instructed to mail letter of appeal.
My question: What should I put in the letter? Information from her recent PT notes? Are there phrases that are particularly effective? Honestly, I'm overwhelmed and confused by all of this and can't tell if websites offering help are scams or what.
Thank you very much in advance.
There may be free help available, and there are resources listed on the MeFi Wiki ThereIsHelp page, including Medicare Rights, which offers a National Helpline at 1-800-333-4114 to answer questions from people with Medicare, their family members, and friends.
posted by Little Dawn at 7:46 PM on May 5, 2019
posted by Little Dawn at 7:46 PM on May 5, 2019
Two resources for getting help-- the Health Consumer Alliance, network of legal aid attorneys who give advice over the phone and sometimes take on cases of this kind, they're very very good and should cover all of California. Your mom doesn't have to be low-income for you get help on this but you'll need a POA or her verbal consent to talk to them.
And CANHR (California Advocates for Nursing Home Reform)-- they sort of have a weird tissue of areas of expertise but if it's something they're helpful on, they are so helpful, I recommend just calling and seeing if you can talk to someone, but their website is a rich resource as well.
posted by peppercorn at 11:42 PM on May 5, 2019
And CANHR (California Advocates for Nursing Home Reform)-- they sort of have a weird tissue of areas of expertise but if it's something they're helpful on, they are so helpful, I recommend just calling and seeing if you can talk to someone, but their website is a rich resource as well.
posted by peppercorn at 11:42 PM on May 5, 2019
Last fall I attended a couple of presentations about selecting a supplemental Medicare insurance plan. The presentations were put on by the state seniors' alliance and had a couple of attorneys specializing in elder care and elder rights to talk about the appeals process for denied claims.
The point they drove home was: know the difference between Medicare Advantage and supplemental plans. Medicare Advantage is a privatized, for-profit plan. It's more similar to a group health policy you get through your employer than it is to actual Medicare. As a privatized plan, you lose the open-access option of Medicare and are confined to the provider's care network. Worst of all, the company gets to decide what is medically appropriate and what isn't, and will deny coverage based on what they deem appropriate (i.e. protecting their profits, not your health). Naturally, they're highly motivated to deny claims for expensive stuff like rehab in skilled nursing facilities.
The presentations I attended were full of furious seniors who'd been in precisely your mother's situation, fozzie_bear: their doctors had prescribed recovery time in a skilled-nursing facility, but their MA provider denied the coverage, sticking them with thousands of dollars in unanticipated medical expenses.
I'd take the attorneys' advice, which was: seek out an attorney/firm in your area that specializes in elder-care issues, including medical claims appeals. The appeals process is very lengthy and frustrating and slanted against the customer, so it would be better to have someone familiar with the process making your mother's case on her behalf.
posted by Lunaloon at 5:36 AM on May 6, 2019 [2 favorites]
The point they drove home was: know the difference between Medicare Advantage and supplemental plans. Medicare Advantage is a privatized, for-profit plan. It's more similar to a group health policy you get through your employer than it is to actual Medicare. As a privatized plan, you lose the open-access option of Medicare and are confined to the provider's care network. Worst of all, the company gets to decide what is medically appropriate and what isn't, and will deny coverage based on what they deem appropriate (i.e. protecting their profits, not your health). Naturally, they're highly motivated to deny claims for expensive stuff like rehab in skilled nursing facilities.
The presentations I attended were full of furious seniors who'd been in precisely your mother's situation, fozzie_bear: their doctors had prescribed recovery time in a skilled-nursing facility, but their MA provider denied the coverage, sticking them with thousands of dollars in unanticipated medical expenses.
I'd take the attorneys' advice, which was: seek out an attorney/firm in your area that specializes in elder-care issues, including medical claims appeals. The appeals process is very lengthy and frustrating and slanted against the customer, so it would be better to have someone familiar with the process making your mother's case on her behalf.
posted by Lunaloon at 5:36 AM on May 6, 2019 [2 favorites]
I had some luck doing this for my mother, first when she was recovering from surgery and needed skilled nursing care and they wanted to send her home/Medicare said they would stop paying, and then when she was getting radiation for throat cancer and wasn't eating and was getting tube feedings I got Medicare to pay for another stint in rehab. I was very detailed about the medical needs, and basically said she was in need of medical care and was in serious condition and her condition was likely to get substantially worse with out skilled nursing care. I'm not sure what did the trick but the magic words seemed to be "medical needs" and "will continue to improve."
posted by Cocodrillo at 10:34 AM on May 6, 2019
posted by Cocodrillo at 10:34 AM on May 6, 2019
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Though information from from psychiatrist about the depression treatment, and ability to engage in PT wouldn't hurt.
Yes your motivated to do the claim, but... this stuff is complicated.
I have had luck as a social worker calling about similar things, and saying something like "this is my first time filling x with your company, what do you need from me to process it?" To meet the formal requirements.
posted by AlexiaSky at 6:58 PM on May 5, 2019