Has anyone ever appealed a Medicare decision and won?

Personally, I think you maybe jumping the gun here. I would first see if Medicare does not pay the bill. Also, see how Moms suppliment handles it. As I said previously, the MC care facility is at fault. The staff should have been aware that Hospice needed to be notified before transporting Mom to a hospital.


So if anyone pays Moms bill, it should be the MC facility, again IMO. The error was theirs. Why should Mom be out the money.

Find an Estate or Medicaid lawyer they have all the loop holes, I have witnessed what they can do for family members who do not care for Mom. If your in NYS Nassau/Suffolk Law is supposed to be able to help at no cost to lower income Elderly.

I suggest you temporarily get her off hospice if you don’t want her to pay the bill. It will be HUGE!!! Don’t wait till you get it in the mail. Hugs 🤗

Ricky6 is right-on. Just as with many governmental agencies there is usually a long appeals process. Almost always, the first appeal is denied.( Try to file for SSDI) There is a slightly less chance that the 2nd appeal will be denied. The 3rd usually hits the sweet spot.

This is the same with many insurance companies, the first 2 are only looked at either by a computer or some file clerk that does nothing but look at the coding and most of the time deny, deny, DENY!!! There are a few codes that hit the spot and are not denied however the third appeal is reviewed by a Dr or a team of Drs who make and honest review of the case.

Good luck with Hospice. As previously stated If the ER visit was for the same diagnosis as the Hospice admittance, then it will most likely be denied, If it is connected to the Hospice diagnosis, it will probably be denied. ie. Hospice is based on CHF. Swollen legs cause cellulitis will not be covered because leg swelling is caused by CHF. However a cut on the leg (without swelling) get infected and results in cellulitis probably will be covered.

Imho, although it may never get to the level of needing an elder law attorney, you may want to retain one.

It’s possible that this is a tug-of-war between the provider and Medicare.

if you are ultimately denied, talk to the provider’s billing office. This might be something that providers expect Medicare may cover in the future, and through repeated billings, they may be hoping to create a precedent.

You are jumping the gun! In regards to your last comment. Besides you cannot do anything anyway until Medicare produces a Medicare Summary Notice. (Period)

Some years ago a friend was involved in something similar and every attempt met with failure. She called me for help and when nothing worked, we threatened to go to the media. Well, I did just that - I went to the television station. As a result, the story and different segments of it were aired on television for five days. She won in the end. No facility likes to be put into the public media - try it and if need be do it - letters to editor, asking them to do a news story, etc. it often works.

I appealed a denial of ambulance service and provided logical reasoning why it should be paid. I won.

Was in hospital for compression fractures of spine and hospital arranged transport because she could not sit up long enough to move to rehab. That bill approved. Rehab ignored signs of a problem (critically low sodium) even w/me telling them to check levels due to symptoms patient complained of. They arranged transport back to hospital when test came back to move her STAT to hospital. Medicare denied the charge because facility failed to tell ems of the critical level sodium test. Hospital treated her several days and arranged transport to another rehab. Medicare paid that one. Based on being paid before sodium problem, after sodium problem and there had been no change in her abiity to sit up for a transport, I used that info to appeal. The judge called me on day of hearing and said common sense played a roll and reversed the decision.

Did you sign an ABN (advanced beneficiary notice)? They (hospice, hospital) would have had to tell you in advance that the service might not be covered by Medicare and along with that an estimated amount of how much it would cost. Sounds simple enough, but I had to fight for over a year with both the hospital and Medicare. It went to arbitration and from there, finally settled. Medicare DID NOT pay, but under contract, the hospital did not provide the ABN form and was in violation. This is the critical part....no ABN, no payment. The hospital had to eat the $10,000 plus charge. The ABN applies to all hospitals and providers that accepts Medicare. It took me a lot of time researching this.....and it seems to be a well kept secret. You have to know what it is to find it.......and then appeal the denial from Medicare (which is another whole process). It's sad to have to jump through all these hoops to get direct answers.....I think it's because they expect you to pay, even at the expense of their own mistakes. Good luck to you. I'd love to know how this works out. Just a reminder.....hold your ground and don't let them intimidate you.

When my Mother in law was w/ Lung Cancer two yrs. ago the hospital stay was DENIED by Medicare.
As her primary caregiver I was called on to appeal that decision. With the help of the hospital Social Worker I commenced doing so on a WEEKEND!

Truthfully, being a nurse & know ALL the medical jargon & understanding it was a HUGE plus. Also, I INSISTED on speaking with the PHYSICIAN handling her case.

Two days later the decision was reserved her hospital was extended & paid in full!

Tips:
1. Seek Social Worker’s help
2. Reach out to any health care worker ( doctor or nurse) in your family/ friends
3. Learn ALL medical jargon & understand it
4. Insist on speaking to Medicare Dr. handling the case.
5. Be Firm, Be Kind, Be Patient
6. Don’t Give up!

Best Wishes & Good Luck
for great outcome.

If it is medically necessary, they should pay Get the Dr to put that on the forms.

Well, what was the reason she was sent to the hospital?

When mom was on home hospice, the reason they told us to call them first before we allowed her to be taken to the hospital was for hospice to give us advice on if it was "necessary" - and one of the things they specifically mentioned was going to the hospital for a fall. If she was sent because we or the EMT's suspected some sort of injury from the fall: ie - a broken bone, a concussion, etc. - then Medicare would pay for the visit, because any such injury wasn't one of the reasons she was under hospice care. But if she went to the hospital for severe edema, there was the possibility that mom would be responsible for the bill, because she was under hospice care for CHF, and edema is a symptom of that. In other words, Medicare isn't going to pay 2 different agencies/facilities to treat the same condition.

I can't imagine the facility your mom is in is not aware of these regulations in regards to hospital visits and hospice. I would try to find out what the reason for the trip to the hospital was and go from there. You might be worrying about something that will never come to pass.

This is the facilities fault. They should have not sent Mom to the hospital without Hospice agreeing to it. IMO.

In your situation any bill you get from the hospital should be forwarded to the hospice agency. Usually Medicare will also handle the situation for you because they are paying the Hospice Agency.

I may be wrong, but I believe that the hospice agency you hired for your mom, should be the ones to contact the hospital, to let them know that all charges be covered by them. I know when my husband was under hospice care in our home and he had to go to the ER, the hospice nurse at the time said that he would call ahead to the ER to let them know my husband was coming, and that it was to billed to them. Well when I got there, no such call had been made I was told, but when I told them it was to covered under hospice, they apparently took my word for it,(I'm sure they looked into it as well) as we never received a bill for it. I would be calling mom's hospice agency and have them handle it. Good luck.