Medicare Is Denying More Claims Than Ever -- Here's How to Fight Back

No matter which type of Medicare you carry -- Original or Medicare Advantage -- you may find yourself dealing with a preapproval or service denial. Claims can be denied for a variety of reasons, including coding errors, Coordination of Benefits (COB) issues, or insufficient proof of medical necessity.

If you have Medicare Advantage, you may have found the past few years especially challenging. Not only is healthcare in retirement expensive, but the non-profit organization KFF reports that Medicare Advantage fully or partially denied 4.1 million prior-authorization requests in 2024 alone.

Image source: Getty Images.

While you probably never considered a Medicare denial as you planned for retirement, all is not lost. Appealing a Medicare denial can be highly effective. While very few Medicare recipients appeal their decisions, the majority of appeals result in Medicare fully or partially overturning the initial denial. Here are the basic steps for making an appeal:

Step 1: Understand the denial

Review your Medicare Summary Notice (MSN) or Medicare Advantage (MA) explanation carefully to understand why the initial claim was denied.

Step 2: Act quickly

You generally have 120 days to file an appeal if you have Original Medicare. If you have a Medicare Advantage plan, you'll need to check with your insurer, as they often have shorter deadlines.

Step 3: Get your doctor involved

Ask your medical provider for a letter detailing why treatment, medication, or specific service(s) are medically necessary. Frequently, a meeting in which your doctor speaks directly with a medical reviewer can turn the tide and get the initial denial overturned.

Step 4: File your first appeal

If you disagree with the decision, file a Redetermination Request (form CMS-20027).

Step 5: Don't take no for an answer

If the first appeal doesn't help and you still believe the initial claim should have been approved, file a Medicare Reconsideration Request (form CMS-20033).

Step 6: Request a hearing

If the Medicare Reconsideration Request doesn't do the trick, request a hearing with an Administrative Law Judge (ALJ). You can do so by filing a Request for Administrative Law Judge Hearing or Review of Dismissal form (OMHA-100).

Where to turn for assistance

The appeals process can feel overwhelming, but fortunately, there are several ways to get help.

• The Medicare Rights Center provides a free national help line at (800) 333-4114.
• Your State Health Insurance Assistance Program (SHIP) can walk you through the process and help answer your questions. To be connected with free help in your state, call (877) 839-2675.
• By filling out "Medicare's Authorization to Disclose Personal Health Information" form (OMB-0938-0930), you can have a family member, friend, doctor, or lawyer help you with the process or even act on your behalf.

Whether you're living on Social Security benefits, a retirement account, or a mix of several sources, it's your hard-earned money. If Medicare denies coverage, you have a right to make your voice heard.

The Motley Fool has a disclosure policy.