Medicare Advantage Problem

My neighbor called me recently about her Medicare Advantage problem.  Renee has a pacemaker to keep her heart beating properly – but she nearly had a heart attack when her Medicare Advantage plan told her she was not eligible to get her pacemaker battery replaced.

Renee’s doctor said her pacemaker battery has about six months of juice left, so she needs to get it replaced.  Renee’s doctor put in a request to her Medicare Advantage plan because just about every medical service requires “prior authorization” by the Advantage plan.  Renee made an appointment for the replacement procedure.

Two days before her appointment, Renee received a letter from the Advantage plan – delivered by Fed Ex.  The letter said the pacemaker battery replacement was denied because Renee doesn’t meet certain requirements.  Renee’s heart nearly stopped when she read the letter.

Renee called the Customer Service number on the back of her Advantage plan id card to complain about the denial of service letter.  She was told she could appeal the denial and that she could fax in forms filled out by her doctor to explain the reasons for the appeal.

Renee knew enough to demand a “fast appeal”.  That’s a situation where the Medicare Advantage plan must review her case and respond within 72 hours (three days).

When Renee told me her story, I said it must be a mistake.  I figured she would win her appeal and get her pacemaker battery replaced – but Renee was pretty upset about the entire incident.

Renee called me a few hours later to tell me she received a phone call from her Medicare Advantage plan.  The company representative said the denial letter was sent to her by mistake and she should not have been told she could not get her pacemaker battery replaced.

That’s quite a mistake!!

What to do when you have a Medicare Advantage problem.

Renee’s case was clearly a mistake, but people who are denied service by their Medicare Advantage plan can appeal.  Actually, they can appeal three times.

If they are denied the first time, they should appeal again,  If they are denied the second time, they can appeal a third time.  And the third time is usually a charm because the case is reviewed by a panel that is outside the insurance company.

The mistake with Renee was quickly resolved, but she said she is going to put in a grievance.  A grievance is a complaint against the Medicare Advantage plan and will get looked at by Medicare.

Medicare has a contract with Medicare Advantage plans and Medicare keeps an eye on the plans to make sure they have policies and procedures in place to fix problems people have with their plans.   Medicare has a star rating system for Advantage plans and too many grievances will affect a plan’s ratings.

I’ve written about a client of mine who had an expensive Medicare Advantage problem:



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