PART TWO OF A SERIES
By Scott B. Elkind, Esq.

In Chinese menu terms, if you order from column A, you need to order from column B. Therefore, it is fitting to address the second appeals component which face denied beneficiaries.

Before an appeal can be made for a Part B denial, the beneficiary must receive an Initial Denial, typically titled an Explanation of Medicare Benefits (EOMB) or, more recently, an Medicare Summary Notice (MSN). Remember, this is the government so we must have acronyms.

Before undertaking the administrative appeal route, there may be an opportunity to resolve these denials. Many times, questions concerning insufficient reimbursement or denials due to insufficient documentation can be resolved by calling the carrier and discussing the problem. Often, resolution may involve gathering additional documentation for submission. If this does not succeed, there is always the opportunity to request review. This request must be filed within six (6) months of receipt of the Initial Denial. For this reason, there is ample time to try to resolve the matter given the length period to request an appeal.

If the review decision results in another denial or otherwise unsatisfactory finding, a beneficiary may request a fair hearing before a carrier hearing officer. To receive this hearing, there must be at least $100 in controversy. If this amount cannot be met by a single claim, multiple claims may be brought together to meet this monetary threshold. If $500 still remains in controversy after the carrier hearing decision, a beneficiary may request review before an administrative law judge (ALJ) before the Social Security Administration. This request must be made within 60 days of the carrier review decision. Should the ALJ decision be unsatisfactory, further appeal can be made to the Departmental Appeals Board within 60 days of receipt of the judge’s decision. Should the beneficiary again be dissatisfied with the Board, finding further appeal filed in the form of a federal court complaint as long as $1,000 remains in controversy.

As you can see, this appeals process can become a lengthy and onerous process of which only the federal government could contrive. I have often made the sarcastic remark that the government has purposefully designed the appeals process this way to discourage people from appealing their benefits denials, hoping that they would be intimidated from proceeding or simply die while waiting for resolution. Although the process may be far from perfect, no one should be left without redress for their grievance. And, where initial resolution is not possible, beneficiaries should avail themselves of the legal process.

Scott Elkind is an attorney in Silver Spring, MD whose practice focuses on disability issues. He can reached at 301-495-6665.