Appealing a Medicare rejection. Any advice?

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My mother had a stroke and a broken hip. She obviously had to be taken to the hospital in an ambulance. The ambulance employee incorrectly coded the form stating only "breathing problems". Medicare rejected the claim ($1,000 to go a few blocks). I appealed to Medicare by filling out and sending in the claim form. No response. Resubmitted the claim. No response. The fire dept responsible for ambulance service will not help. They will NOT resubmit the claim. NOW what can I do?

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Eric, the post office used to require a street address for certified mail but for the last few/several years it will deliver certified mail to a p.o. box. I imagine they leave the notification slip in the box, advising that a certified letter is pending delivery so the recipient can make arrangements to pick it up.

If the expiration date for the appeal is close to expiration, send it again by use FedEx or USPS overnight mail and make sure you check the section to get a signature receipt.

Is "unnecessary" the code Medicare used in the EOB? Even if that conclusion was made, shortness of breath can be a medical emergency, so I'm wondering if something else was involved. Were there other codes that were indicated as justification for the denial?

This is what I did when the appeal I filed was denied. I wrote again, in accordance with standard Medicare rights to challenge their appealed decision.

For each conclusion stated in their denial letter, I asked them to identify the names, type of doctors, medical specialty, specific record from the hospital on which their decision was based, and the justification. I.e., why was CHF not considered justification for admission? Which doctor made that conclusion, what was his/her specialty, etc.

The decision merely listed that - just a decision on a medical issue. I had no idea whether doctors or just bureaucrats were involved. So I requested specific information.

The next time Medicare wrote it was to apologize for a delay in responding and ask if I still wanted to pursue the appeal. I did. I never heard from them again. By that time the hospital as well had given up.

If this fire department is a municipal rather than a private one, I would start going up the chain of command to get results. Find out if your town/city/township has a supervisor, or an ombudsperson and contact him/her. Or contact an oversight board for the municipality.

If the fire department is private, check with your state to determine what kind of corporate entity it is, research state corporate files to find out who the principals are and contact them.

Again, document, and send by certified, registered or overnight mail.

Have you gotten the hospital records yet to support the diagnosis of broken hip? That should be high on your priority list as it will refute the records of the FD.

Sure, you can call a legislator; some do have troubleshooters that may help. But do it quickly, and call several as I've found they don't always act quickly.
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I sent the claim in twice. No response. I didn't know it could be sent certified. I thought you had to have an actual address for that, not a PO Box. The expiration for claims is approaching. The fire dept in question is UNWILLING to cooperate. Others have told me how uncoopeartive they are. It is ridiculous to think that a iniety year old with a broken hip, stroke and other problems (noted on the hospital dischardge report) could be denied an ambulance on the grounds that it was "unnecessary". I had thought of calling my congressman. Is this an option? Don't they have people who deal with these issues?
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Hi Eric - You shouldn't have to appeal this to Medicare. Unfortunately, there are some unscrupulous ambulance companies out there. Explain to them that if they wish to get compensated, they need to check their chart notes for the call, correct the claim and resubmit it to Medicare.

If they don't want to cooperate and try to threaten you with Collections, you may want to remind them that the Collection Invoice will be 'Contested' within 30 days of receipt, at which point, it will be THEIR responsibility to provide PROOF of a correct billing. Hopefully, it won't get to that point.

This has gotten to be such a huge problem that new legislation was recently passed: http://time.com/money/3737140/credit-score-medical-debt/

Good luck.
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I assume you submitted the claim in accordance with the terms stated in the Medicare Explanation of Benefits? If so, send it again, but send it by certified, registered or overnight mail so that you have proof of receipt.

I've submitted only one claim; it took Medicare quite some time (several months) to respond. In the meantime, I went after the hospital since the issue arose from erroneous entries by the hospital in considering the overnight stay "observational" rather than an admission, and the need for overnight stay was caused by their actions during surgery.

If you don't have a copy of the ER and subsequent hospital surgical reports, get them ASAP. Copy the relevant portions and send them to Medicare, again by a method that provides you with the signature of someone who signed for them.

It wouldn't hurt to share the hospital records with the FD and point out the incorrect coding. If you have to, try to go to the administrative level, beyond the EMTs, and speak with someone in the billing department. Then follow up with another letter.

Obviously, keep your own documentation of everything you've done. When I appealed a Medicare decision, I did that, so I could address any errors or omissions they made.

Also, be sure that you're addressing the specific letter code Medicare uses to explain rejections. It's on the EOB.
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