Can Medicare Deny Coverage?

Have you ever been sitting in the doctor's office worried about if you're going to have coverage for whatever treatment your doctor recommends? Fortunately, you don't have to live in fear that Medicare will deny you coverage.

As long as you are following the rules of your plan, you should have no difficulties with Medicare coverage. However, claim denials do happen. We're going to look at the reasons why Medicare might deny coverage and what actions you can take if that happens.

Why does Medicare deny coverage?

There are a few reasons why Medicare can deny coverage. It's important to understand those reasons. If you can understand the rules and have checked the Medicare website to see if that service is covered, you should be fine. However, it is important to remember the reasons Medicare denies coverage:

• It is determined that you are not following the plan rules. The plan rules are there to help you find coverage. Failure to heed the rules can lead to denied claims.
• It is believed that you are receiving services that are not medically unnecessary. The most popular examples of this type of service are cosmetic procedures and some forms of plastic surgery.
• Your treatment is part of a clinical research study. Many plans only cover partial costs of studies. Talk with your doctor about your Medicare coverage plan before starting the trial.

What happens if my coverage is denied?

If your Medicare plan denies coverage that you think should be covered, you can file an appeal and have the case reviewed. The appeal process changes slightly based on what type of coverage you have and what kind of coverage was denied. To learn more about the appeal process, check out the information on the Medicare website.

How do Medicare Advantage plans differ?

Medicare Advantage plans are different than Original Medicare because they offer private coverage options, which means the rules for your particular Medicare Advantage plan may differ from the rules from other providers.

One reason you might be denied coverage is because you saw a provider that was outside of your network. Medicare Advantage HMO plans, in particular, have strict rules about staying within their provider network. If you went outside of that network for service, then your claim will likely be denied. There are exceptions for this, such as emergency care, but it is always safer to find an in-network location for most medical care items if your plan requires it.

Because there are a large variety of MA plans, it's important to check your individual plan's coverage rules as your coverage rules may vary from the ones listed above. The variety of MA plans means that you are more likely to find a plan that covers your needs in your area than if you go with Original Medicare. If you disagree with your plan's determination, you can file an appeal directly with the plan for reconsideration.

How to avoid claim denial

The most important thing you can do to avoid coverage denial is to familiarize yourself with your plan and its limitations. Knowing your plan is the best safeguard against claim denial. You can review your plan by looking up your plan information on your carrier website or on Medicare.gov if you have Original Medicare.

The other thing you can do is review your coverage. If you find yourself facing denied claims, it might be a sign that your current plan is not meeting your needs anymore. If that's the case, then it might be time to make a change.