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An 80-year-old patient with congestive heart failure and diabetes falls and breaks her hip. After surgery, she is transferred to a nursing home to continue her recovery.
After two weeks in the nursing home, her Medicare Advantage insurer issues a notice denying payment for her continued care. The patient appeals the decision, kicking off a five-level process that can carry on for several years.
Here is how it typically unfolds:
Step 1: The patient appeals directly to the plan, submitting evidence to rebut the denial. The appeal is rejected. The plan upholds its initial decision.
Step 2: The case is then forwarded to an outside entity known as a quality improvement organization (QIO), an entity hired by Medicare to review payment denials. The QIO reviews the records and again upholds the insurer’s denial. These first two steps typically unfold in less than a week, but some cases take longer.
Step 3: Still unsatisfied, and on the hook for thousands of dollars in additional care, the patient opts to spend $180 to file an appeal with the Office of Medicare Hearings and Appeals, which assigns the case to an administrative law judge. Depending on the backlog of cases, it can take several months to more than a year to get a hearing. After a hearing is held, a judge either upholds the denial, partially overturns it, or completely overturns it and orders the insurer to pay in full.
Step 4: If the patient disagrees with the judge’s ruling, she can spend another $180 to file an appeal to a special Medicare appeals council. There is no timeframe for this decision. It will likely take months to review the case and decide whether to uphold the judge’s decision or reverse it.
Step 5: The final step is to appeal to a federal district court, as long as the case involves at least $1,760 in disputed expenses. Again, there is no timeframe for this decision, which likely comes after spending more than two years fighting the initial payment denial. In some cases, beneficiaries give up or die before reaching this step.