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Medicare: Do You Know All You Should?

Appeals - Step One: Request For Reconsideration

Steps in Appeal. Whenever you believe a wrong or incorrect action was taken by a Medicare official, you should submit a written request for a reconsideration of this decision. You should put all of the supporting evidence and documents which you have into this letter of reconsideration. To help your case, you should provide documentation for any issue which might better help the officials at the administrative agency understand your position. Also, a request for reconsideration generally involves a person who has not yet been involved in your case, and simply may not have any knowledge of the points of your argument. To determine if you need additional documentation, you should engage in the following analysis:

Write down the specific problems with the agency decision. Then under each problem, if there is more than one, write all of the reasons why you disagree with the agency's decision. Then for each reason, ask yourself if there is documentation which supports this reason in your Medicare file. It's a simple analysis. Is there likely to be support for your position in your file? If you conclude yes, be sure you direct the agency administrator's attention to where they can find it. Providing copies, if possible, in your letter of reconsideration and even highlighting the relevant parts of your copies is extremely helpful.

Legal Issues: For example, if your question is about the recommended treatment prescribed by a physician which was denied by the Medicare agency, directing the administrator's attention to page 3 of Dr. Smith's report, third paragraph, where she recommends and insists on such treatment, may help your case, particularly where there are a number of physician reports to sift through.

If you are uncertain that there is documentation for your position in your file, make sure you take the steps to get it. For example, assume there is a dispute about whether your treatment at a hospital for a lump in your leg, and your 10-day stay at a nursing home, was actually prescribed. How can you support your case that Medicare should pay for the 10-day nursing home stay? You can try several things. If you are not sure if your doctor's prescription for nursing home care is in your file, or if you do not know if it was prescribed for 10 days, you can attempt to secure statements, in writing, from other doctors, hopefully approved by Medicare, that they would have prescribed 10 or even 20 days, given your medical situation. Also, several doctors might disagree with your Medicare physician that your nursing home care was absolutely necessary for some medical reason, e.g., that if you put weight on your leg for the first 8 days after the treatment, that the condition would have returned, and worsened. [We are not concerned with the actual medical specifics, but are just using these facts to illustrate how to support your position.]

Medicare: Do You Know All You Should?
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