Family Health Legal Library

Medicare: Do You Know All You Should?

A Look At Some Kinds of Disputable Situations

What if Healthcare Services Received Are A Problem? If you believe that the healthcare services that you were provided by a physician or other Medicare specialist were insufficient, deficient, or otherwise below an acceptable level of medical care, you are entitled to a review of your situation. Generally, Medicare has specific provisions which govern a review of the care you were provided. These review organizations are called Peer Review Organizations and are specifically paid by Medicare to audit and review the services provided by the Medicare health professionals.

To institute a complaint or inquiry under this system, you should call the local Medicare office and make a formal request in writing of your desire to have the services reviewed. The specifics are subject to statutory changes and as such, any outcome of potential disputes cannot be predicted with accuracy in this discussion. You should make sure that you remember two important points which will likely influence the Peer Review Organization in its determination of your case.

First, the standard of review is not whether you think that you were not provided certain services or a certain level of care. Rather, the standard is whether the services provided met a reasonable standard of care available in the medical community. This means that you should give serious consideration to your situation before you even think about instituting a review, since the care which you were provided may meet this standard even if you do not believe the care was proper.

Second, you should remember that you need to be sure that, prior to your review, every piece of information available to support your case is in your file. Often patients will complain about services, because, for example, a nurse tells a patient that a doctor should have done a specific procedure when she did not. As a patient, you agree and become quite agitated that your physician did not provide certain care. You appeal for a review and during the review, it becomes clear that the nurse's statement is not anywhere to be found in your file. As a result, the peer review group cannot consider the nurse's statement and will not measure the standard of care in this manner.

Most important to this entire area is that you should consider seriously obtaining a second opinion about whether the care you were provided actually fell below the level of care which physicians are supposed to provide. If you believe that the care provided to you might fall below such a standard, you ought to investigate further. You might seek another opinion to determine if another doctor believes that your suspicion is correct. If you can obtain a statement from this second or third doctor, you might be sure to bring this to the attention of the Medicare Review Organization. You might also want to discuss this with an attorney, in many instances, even before the Peer Review Organization. You might review the details of substandard medical care, and that section should be consulted before you proceed further.

What if I Was Overcharged By A Physician? Medicare has a system of reviewing charges by physicians. You can contact either Medicare or your Medicare carrier and file a complaint with them if you believe that you have been overcharged. They will set up an inquiry to determine if the charges meet their schedule of charges. Medicare has a published list of charges and you may wish to consult this list of charges. Remember that this list will vary by state in many instances and will also vary by state law.

What If the Hospital Will Not Admit? Often, this might be a serious problem. Many hospitals may have various procedures for admission which may make it difficult for you to be admitted. Also, many hospitals may seek to interpret their own rules, or Medicare rules, so that they do not have to admit certain patients. You should be on the lookout for this possibility whenever you enter the hospital.

In almost every serious illness case, not including a situation where one might be attempting to be admitted to the emergency room for treatment of a cold, you may wish to consult with a lawyer. Whether you consult with the lawyer before or after you have been denied admission can make a difference in many cases. Documentation of your denial of admission and the reasons therefore should always be in writing, and you should always insist that they be in writing. Your attorney can evaluate these to determine if you have been wrongfully denied admission.

Also, this is an area in which you may seek to invoke the Appeals Process discussed below and you may want to review those procedures here.

What If There Is A Denial of Payment? Once Medicare denies a coverage or a payment, you are entitled to invoke the procedures in the Medicare system. While these measures are designed to protect you, you must remember that these are legal rules and may require legal interpretation at times. Also, remember that everything has time limits, which if waived, may force you to lose your rights no matter how correct your position is. It might be wise, depending upon the seriousness of your case, to seek the advice of counsel.

For example, if you have been denied a specific treatment for a cancerous growth, you may need to employ the services of an attorney to find out the basis for your denial and whether there is anything an attorney can do to overturn such a denial. However, if you are complaining that Medicare did not pay for a teeth cleaning during your oral surgery, you might be able to follow the appeal procedures yourself. Remember, we are not deciding the importance of medical problems. All medical problems can cause harm, problems, and irritation. The question is merely, when does it make sense to hire the services of an attorney?

Medicare: Do You Know All You Should?
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