Denied!
If you or a loved one has a Medicare Advantage Plan, here's something important to know: A denial is not always the final answer.
Many people don't realize that Medicare Advantage plans often require prior authorization (pre-approval) before they'll pay for a stay in a skilled nursing facility after a hospitalization. If the insurance company says "no," you have the right to appeal that decision.
A recent report from the Office of Inspector General (OIG) found that the 19 largest Medicare Advantage companies denied up to 12% of requests for skilled nursing facility admissions. Even more concerning, they denied 40% of requests for people who needed to continue receiving skilled nursing care.
The good news? When families appealed those decisions, 95% of the denials were overturned. That means many people who were initially told they didn't qualify actually did.
So why aren't more people appealing? According to the report, only 18% of denied claims were challenged. Many families simply don't know they have the right to ask for a second review.
If you receive a denial for skilled nursing care:
Don't assume the decision is final.
Talk with your doctor and ask for documentation explaining why skilled care is medically necessary.
File an appeal with your Medicare Advantage plan as soon as possible. If time is critical, ask about an expedited appeal.
Navigating Medicare can be confusing, especially during a health crisis. But knowing your rights can make a tremendous difference. Sometimes, the care you need is only one appeal away.
Jacqui Clark is a Certified Senior Advisor™ (CSA™) senior care consultant & placement agent with Living Coastal Senior Resources. She is the host of Get Ready for Better Aging podcast. She is an industry-leading expert on living and aging well, as well as a respected communications specialist. Jacqui@LivingCoastalSR.com www.ThisIsLivingWell.com