How Can I Increase the Odds That Medicare Will Cover My Medical Service?

A fellow caregiver asked...

How can I increase the odds that Medicare will cover my medical service?

Expert Answer

It's usually obvious whether a medical service is covered by Medicare Part A or Part B, or by a private Medicare Part C (Medicare Advantage) plan. But occasionally Medicare, or a Medicare Part C plan, denies payment for care that a patient expects to be covered. Common situations include the following:

  • The patient repeats a procedure, even though previously it was unsuccessful or only temporarily or partially successful.

  • The patient undergoes a screening or procedure more frequently than Medicare's normal time frame permits.

  • The patient begins or continues an ongoing service, such as nursing-facility or in-home healthcare, though not -- or no longer -- meeting all required conditions.

But these are only examples. There can be a gray area between covered and not-covered care with almost any treatment or procedure. The key is whether the care is "medically necessary," a basic requirement for all Medicare coverage.

There are several steps you can take to increase the odds that Medicare, or a Medicare Part C plan, will cover your care. Your doctor's participation is crucial in dealing with coverage issues, but there are things you can do to help your own cause:

  • Recognize when there might be a problem. When you're about to obtain a medical service, check Medicare coverage rules to see if your specific situation might straddle the line between coverage and no coverage.

  • Discuss the service with your doctor beforehand. If you have any doubt about coverage for the service or treatment you're about to begin, discuss coverage beforehand with your doctor. Medicare and Medicare Part C plans rely on a doctor's notes about a patient's condition in making the coverage decision. Bringing up the coverage issue ahead of time will alert the doctor to make notes about you that establish medical necessity, thereby increasing the odds that you'll be covered.

  • Ask your doctor to contact Medicare prior to starting the procedure. If your doctor agrees that coverage isn't a certainty, he or she can contact Medicare or your Medicare Part C plan and request approval of coverage before starting the care. If coverage is denied, you and your doctor can then take further steps -- your doctor can provide Medicare with more information; your doctor can provide you with other, preliminary care to satisfy Medicare; or you and your doctor can discuss alternative types of care.