When Medicare denies your claim — 9 tips for a successful appeal

Going through any medical procedure is stressful. When it’s a surgery such as phase two of DIEP flap breast reconstruction, you think the worst part (phase one) is behind you. And it is.

However…

The nightmare that is medical coverage denial is no picnic either.

Don’t assume your insurer will have your back and that all costs of your phase two surgery (or any procedure) will end up being fully covered.

Interestingly, it appears that denials are on the rise as explained in this article.

When you receive an unexpected bill for what you thought was going to be covered, it is NOT fun. Not one little bit.

When this happens, what do you do?

Everyone’s situation, including medical procedures and insurance coverage, is different. I’m sharing about my experience with a Medicare claim denial hoping it might help you should experience the same.

First of all, since I’m now of a certain age, I am on Medicare. This post is specific to Medicare, but I’m thinking it might be relevant regarding other insurance carriers as well.

I underwent DIEP flap breast reconstruction surgery August of 2020. Yep. Smack dab in the middle of the COVID-19 pandemic. It was originally scheduled for April of that year. It was postponed abruptly. (Long story, lots of stress)

Phase one was rough, but doable. And Medicare covered the whole shebang. No questions asked.

You can read about my DIEP flap experience/results here and here and here.

I also wrote about the peculiar twinship of my DIEP flap surgery and the pandemic in my new book, EMERGING

When time for phase two rolled around (yep, still during the pandemic), I was ready and thought I had all my bases covered.

Phase two was in August 2021. Sometime later that fall, the unpaid portion of the bill came. And at nearly 5K it was not a small-potatoes kind of bill one would just shrug off and reluctantly pay.

Surprise!

Upon closer scrutiny of the summary, claim denial, and subsequent remaining bill, I quickly became irritated and then angry — after being shocked, of course.

The problem seemed to be wrapped up in the word ‘liposuction’.

When whoever reads and decides to deny this stuff doesn’t fully understand or fails to take the time to read the patient’s entire record (about the particular medical procedure) and instead, jumps to the ‘that’s cosmetic (based on one word — liposuction) and therefore we don’t cover it,’ conclusion, it riles a person up. Well, this person anyway.

I decided right then and there I was going to appeal that Medicare denial.

How dare they say any of this was cosmetic. It was reconstructive, not cosmetic.

…liposuction is a technique that is used for various reasons both cosmetic and reconstructive. They cannot say that it is only a cosmetic procedure and deny coverage.

Minh-Doan Nguyen, M.D., Ph.D. (My DIEP flap plastic surgeon)

So, where and how do you even start an appeal?

I had no idea.

Hence, this post. Perhaps it can be a starting point for you should you need one, though I hope you will not.

Here are 9 tips to make YOUR appeal easier:

1. Keep track of all paperwork, and electronic stuff you have access to, related to all parts of any procedure. Documentation is key.

Some of us, including me, suck at keeping medical records (okay, anything) organized. Try to do it anyway. Or have a loved one do it for you.

On top of this, once you decide to appeal, keep a record of everything regarding your appeal too.

2. Contact your medical institution right away AND your insurance provider to let them know you are appealing and will NOT be paying the disputed bill.

3. Document all above-type contacts in #2. Include dates, times, and names exchanged via phone calls.

I used my patient portal for communicating with Mayo Clinic. I contacted Medicare by phone and by letter.

4. When writing messages/emails, even on your patient portal, be clear, firm, and respectful. Always. Also, check for spelling/grammar errors.

When writing emails, and especially when sending snail-mail letters, use proper letter formatting and etiquette. If your correspondence looks sloppy or incoherent, you won’t be taken as seriously.

5. Follow all instructions (yeah, I know it can be a pain) for how to appeal a decision — if you are given any.

Medicare had steps for “how to appeal” right on the bill. (I’m thinking this means this sort of thing happens fairly often.)

I carefully followed every direction and mailed all documents as requested well before the deadline. I made copies of everything for my own files.

6. Get your doctor on board.

This step is crucial. I contacted my plastic surgeon right away and asked for a signed letter supporting my appeal. She responded the same day with a strong letter of support explaining the situation.

7. Make copies for your records.

This is really the same as #3 above, but it’s worth mentioning again as it’s so important.

8. Understand (or try to) the reason for the denial.

You can’t call them out if you don’t take the time to fully understand the reasoning behind the denial. This might require you to read and reread their denial paperwork many times. Generally, there’s a short explanation regarding why a claim was denied.

9. Be prepared to be persistent and patient.

I know this probably isn’t what you want to hear. However, you will need to be ready to keep going. If you feel strongly that your claim should not have been denied, don’t give up! Persistence is key. And patience is required as well. This whole process was a lengthy one for me. I’m thinking, from start to finish, it took about nine months.

I had to go two rounds when appealing. The first time I got an unfavorable response.

And yeah, I thought about giving up. But I KNEW I was right. Plus, $5,000 is not an amount to sneeze at!

Going another round wasn’t that hard. Again, I followed the outlined steps given on the forms and basically, just repeated everything. I wrote another letter — this one a bit, okay a lot, more forceful — and sent it off before the deadline.

Another round sometimes means the decision will be made by an independent party, which can be a good thing as it means new eyes will be looking at your files. This turned out to be beneficial for me.

Again, I contacted all the relevant players to keep all abreast on what was happening. I figured if I was going to be delinquent in payment, at least everyone would know why.

Of course, even though I contacted Mayo, I kept getting annoying messages telling me I was delinquent in paying my bill. There was even a threat that said something along the lines of if the bill wasn’t paid soon, medical care/coverage for other family members might not be available. Really? That was irritating, and yes, I told them so.

When the envelope arrived weeks later containing the third verdict, needless to say, I was nervous. I made Dear Hubby open the envelope and read the letter first.

Lo and behold there it was — a FAVORABLE decision!

Those words were music to my ears.

Self-advocacy is hard (and frustrating) sometimes. But always worth it.

Bottom line, if you feel a claim has wrongly been denied, go ahead and start that appeal.

After all, it’s your life, your cancer (sorry), and your pocketbook.

I hope me sharing my experience helps you with yours should the need arise.

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A NOTE FROM NANCY: Order my new book EMERGING HERE. EMERGING is also available at most online booksellers such as: BAM, IndieBound, Bookshop.org, Barnes & Noble, and more.

For a sample, read the first 20 pages via my Resource Library where you can download them for FREE.

Have you ever had an insurance claim denied?

Have you ever filed an appeal?

Do you have a tip to add?