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ACS CAN issues report on complicated Medicare appeals process

​A confusing process leaves patients at risk for delayed or denied care.

As millions of seniors and other enrollees select their 2021 Medicare health benefits during annual open enrollment, a new ACS CAN report details just how confusing the program’s appeals process can be should a patient need to appeal a claim denial for health care services or prescription drugs.

The report examines the myriad complex steps, documentation, and timelines involved in appealing denied Medicare claims and how the process might impact patients. The report comes as Congress faces a two-year timeline to act on the projected insolvency of the Medicare Trust Fund—action which is likely to include changes to seniors’ Medicare coverage options that could result in out-of-pocket cost implications.

“When lawmakers consider significant changes to Medicare enrollee benefits, they often cite the fact that patients can always appeal a decision. Rarely, however, do they consider what the appeals process actually entails,” said Lisa Lacasse, president of ACS CAN. “This report found the confusing and often lengthy appeals process left patients waiting for a decision while their cancer and other symptoms were left untreated.”

The report’s key findings include:

  • The Medicare appeals process is overly complex and various timelines and documentation requirements can create barriers to care.
  • Many beneficiaries do not exercise their right to appeal and instead might choose to pay out of pocket for services that should be covered by Medicare or choose to forgo care altogether, which could have negative implications for their overall health and wellbeing.
  • Evidence suggests Medicare plans’ default is to deny claims as plans overturned 75% of their denials upon appeal.

Appeals timelines vary from a few days, under expedited circumstances, to several months depending on the type of appeal and which part of Medicare it falls under. Terminology varies widely as well making the whole process potentially daunting and likely dissuading people from filing appeals.

Suggested changes to improve appeals for patients include, streamlining the various appeals levels, simplifying and standardizing terminology, providing more oversight into appeals, and allocating more funding to help beneficiaries use appeals when necessary.

“Those on Medicare are often on a fixed income and are dealing with multiple health issues at once. Being able to get the care they need in a timely manner and at a reasonable cost is essential to ensuring their wellbeing,” Lisa said. “If the Medicare program is going to require beneficiaries to utilize the appeals process to access necessary services, lawmakers must do everything they can to make it as user-friendly as possible for those who need timely access to evidence-based treatment.”

View the full Medicare appeals report.

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