Do I have any Recourse if my Medicare PPO Plan refuses to pay for medically necessary care?

All Medicare Patients have rights that are protected under Medicare. This includes patients who are signed up under Medicare PPO Plans. If you think you have had a procedure that is medically necessary and is covered but your plan refuses to pay, you can file an appeal. A right to an appeal is part of the rights that you are given under Medicare.

What is a Medicare Appeal?

A Medicare appeal is basically a complaint against the PPO plan and Insurance Company for payment refusal. In this complaint a patient need to explain the situation in detail and describe the type or service or equipment that they received. The patient also needs to explain why the item or service was medically necessary and should be covered under Medicare and by their PPO Plan. When preparing your appeal it is a good idea to gather as much information from your doctors and other providers as possible. Their extra input will help to decide the appeal in your favor.

Once you file the appeal and hear back from the insurance company, if you are still unhappy with the outcome you can file a further appeal directly to Medicare. Medicare actually contracts this process out to another private firm. If this appeal also fails you can ask for a further appeal. Sometimes it takes a long time to get these appeals through but there are stories of people being able to provide lots of documentation and winning massive appeals cases.

Patients who feel they are being discharged too early from the hospital can also demand an immediate review by a Quality Improvement Organization. These are groups of doctors that review cases to ensure overall quality control standards are met. You will be allowed to stay in the hospital while your case is being reviewed. In some cases this is extremely important because Medicare will not pay for skilled nursing home care unless a patient has spent three nights in the hospital. If you feel you are being discharged too quickly stand up for your rights and request a QIO review! Fast tracked reviews are also possible in almost all levels of care. If you feel your health is in jeopardy speak up!

Auntie Lou says, "The squeaky wheel gets the oil."

In summary, just because you join a PPO Plan doesn't mean you are giving up your right to an appeal. In fact, the opposite is actually true. You have more levels of appeal to go through and therefore more chances to win your case!