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

17 answers | Last updated: Nov 02, 2016
A fellow caregiver asked...

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


Expert Answers

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.


Community Answers

A fellow caregiver answered...

helpful


A fellow caregiver answered...

My doctor said that I won't die if I don't have the operation. I just can't walk or stand. I think this is a medical necessity. What do you think?


Scared stiff answered...

So far this site is all mumbo jumbo


Lisbet answered...

If I had known this beforehand, my insurance may have covered this. Good info.


A fellow caregiver answered...

any additional info is power in being ones own advocate


A fellow caregiver answered...

Medicare will pay for anything you need if your Dr contacts Medicare ahead of time and explains the situation regarding what you think is medically necessary and your dr wil back it up. I spoke with a Medicare Supervisor who called me at the requaet of President Bush, and this is what she told me. Your Dr has to caontact them and explain why you need thhis procedure done. If you just go do it without prior contact, you are taking the risk of denial.

She also told me that what the general "rules" are for payment of procedures, testing, etc, set by Congress, are merely general rules for what they wil ordinarily pay for, but each patient is different. Thus the necessity of prior contact with Medicare to discuss YOUR particular situation. Mostly they will not deny the service or procedure.

Hope this helps you - it really helped me. I had thousands of dollars worth of procedures and tests they did not want to pay for. It was prior to Pain Management being coded and Congress had not acted on it yet. However, they paid for every single penny of those bills after my Dr called them. I thinnk it is now referred to as a "Prior Authorization". They also use trhis phrase for any Medications in Part D billing. Certain meds require Prior Authorization, or you willl have to shell out for these meds. If your dr fills out a form that your insurance company has, and faxes it in or gets it to your pharmacy and they fax it in, it will be approved in either 24 hours or 72 hours, depending on the form Dr uses. They have their rules and each insurance carrier is a little different, so check your book of rules they send you in January of each year - things change also..so be sure to read the darned booklets! LOL


Dallasailor answered...

I've been totally disabled since 1993. My husband has been my caretaker. Now, at 72,he's finding it difficult with no relief. Are ther any provisions to relieve him for short periods at a time, or for home help to relieve him of everything?


A fellow caregiver answered...

In the last ten years, I have had personal experience of needing Medicare coverage for treatments, surgery, medications,intensive rehab therapy, home care, etc. many of which, according to Medicare rules, were not covered but mine were, mostly thanks to good records kept by my doctors, especially those by my primary doctor.

Believe you me, the more you know about Medicare rules and regulations as well as how helpful primary doctors are (or are not)inclined to give Medicare their honest professional opinion - via their records of ones regular visits and treatments, the better the chances of Medicare approving whatever is needed to put you back on your own two feet.


Clarav answered...

mY HUSBAND HAS EARLY aLZHEIMERS - MEDICARE WILL NOT PAY FOR PHYSICAL THERAPY AT ALL - THEIR STORY IS IF HE CANNOT IMPROVE THEY WILL NOT PAY FOR IT. iN OTHER WORDS THEY'VE JUIST GIVEN UP ON HIM. tHEY CLAIM THEY WILL NOT PAY FOR MAINTENANCE - WHICH INB THIS CASE IT IS HELPING HIM WALK AND BALANCE. iT'S SO IMPORTANT SO WE'RE PAYING $45.00 TWICE A WEEK JUST TO KEEP HIM WALKING AS LONG AS IS POSSIBLE. dOESN'T MAKE SENSE - THEY'VE JUST WRITTEN ALZEHIMER PATIENTS OFF..... NOT FAIR

Clara V


Comamom answered...

ClaraV, my mother has Alzheimer's and my son has a Traumatic Brain Injury (TBI). The government has thrown both Alzheimer's patients and the brain injured under the bus. My son has a 4 year old son who receive NOTHING from neither the State nor the Feds as my son was only 19 when he had his accident so he had not paid enough into the system...What about all the money my parents and I have paid into the system all these years? I cannot believe the government does not consider the "brain" part of the human body...prayers for you.


A fellow caregiver answered...

The expert is right about "medical necessity" and having the doctor on board is crucial to explaining patient conditions to Medicare. Although speaking with Medicare, I have found that they received invoices for services we have not yet received and invoices for services we received that they have not. It's like the left hand doesn't talk to the right. So on the advice of Medicare we were told to hold onto all invoices in case they didn't have a copy and vice a versa.


Daretothink answered...

Reading the comments of people not receiving medical coverage posted here says it all...if American citizens don't have money, they are expendable. Our government doesn't want us taking up "space" anymore and if we die, its more money in "their" pockets. This is capitalism...this is social Darwinism...disparaging.


Daretothink answered...

What happens to people who don't have the capabilities to do this research prior to receiving medical care? They die.


A fellow caregiver answered...

My mom has Alzheimers and Dad is trying his best. No help with funding that I can find. Should be more help in 2014 when ObamaCare starts - Thank goodness.


A fellow caregiver answered...

medical necessity is a term used by insurance company including Medicare which is really related to coverage decision. it is a term which is meant to deceive. it is a term used by insurance companies to make it look like a certain test or procedure it is not medically necessary,when in fact it is whether a insurance company will cover it or not. insurance companies attempt to insulate themselves by not covering something and rationalizing that it is a coverage decision and not a medical decision. and this is meant to help protect them from a lawsuit in case they are sued for not covering a necessary procedure and the patient suffered a harm because they would not cover it. but any rational person would clearly recognize and a noncoverage decision could cause harm but they feel protected under this law however if the patient is harmed because they will not cover a necessary procedure that can be sued in federal court but not state court. and just because an insurance company does not cover it,does not mean that the patient cannot have it,but they would have to pay for themselves. and prior authorization is definitely being abused with medication and when a expensive test is to be done. however the best way to prevent a rejection of a claim is to make sure that the test or procedure or study is covered beforehand in elective cases ,meaning nonemergency but the medical code for the test or procedure has to match a covered diagnosis or reason to do the test. so a lot of times it is a proper coding issue but because test can be expensive and ordering test can be very easy it could bankrupt the system if frivolous test are ordered. so it is very prudent to help make sure that if something is expensive and which cause a significant financial burden to the patient,in case it is rejected and nothing is worse than an unanticipated cost to a patient. test and procedures do have specific reasons to be done and correlating the two can save a lot of problems and headaches. and when they refused to cover a preauthorization,the physician and the patient can file an appeal so medical necessity is an insurance term for coverage and does not mean it is not medically necessary. a battle that has to fought every day by doctors and patients against insurance companies. but without any accountable system frivolous and unnecessary test which can sometimes be harmful also. so matching the diagnosis and the medical code has to correlate.


A fellow caregiver answered...

Doctors, hospitals, Nurses. e.t.c with the exception of the Emergency Room are suppose to provide you with medicare advance beneficiary notice(ABN) if the procured or service is not covered. You have options listed on ABN. The form you sign at some places saying you will pay for the service if Medicare or Medicaid does pay. That form is technically not valid, because it doesn't give you the 3 choices Medicare requires. On another issue, for those saying Medicare won't cover service that is normally covered, You can appeal that decision.