Hot Topics in Health Care: Medicare Reviewing Denied Claims

As part of the settlement of the Jimmo v. Sebelius lawsuit, in which Medicare conceded that coverage is available for skilled services to maintain or not diminish an individual’s condition, costing unnecessary cost and coverage denials, Medicare is reviewing previously denied claims.  What this means is that if you had a Medicare part A or part B claim denied, in part because it was determined that your condition plateaued or you didn’t show improvement, between January 18, 2011 to January 23, 2014, Medicare will review your claim, utilizing the new standard and may reverse the denial.

More specifically, a Medicare beneficiary may be eligible for the review of a past claim, if they:

1)      received skilled nursing or rehabilitation services in a Nursing Home, Home Health Care or  Outpatient therapy; and

2)      received a partial or full denial of a claim based on the fact that they lacked improvement ; and

3)      The denial was final and non-appealable on or after January 18, 2011.

Appeals are always time sensitive.  If a claim became final from January 18, 2011 to January 24, 2013, the deadline for the review is July 24, 2014; if a claim became final between January 25, 2013 to January 23, 2014, the deadline to file for the review is January 23, 2015.

You can access the appeal form on the Center for Medicare Advocacy’s website: www.medicareadvocacy.org

 

   

About Author

  • Email: mlamagna@hhrls.com
  • Michael LaMagna, LNHA, MPA, JD concentrates in the areas of Medicaid and Advanced Asset Protection Planning, Elder Law, Trusts and Estates, Probate and Probate Litigation, Guardianships, Health Care Regulatory Matters, Nursing Home Placement, Long Term Care Insurance, Medicare Appeals, Social Security/SSI Litigation and Special Needs Law. If you have a question for Mr. LaMagna, please call him at (914) 437-5955.