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Why Your Medicare Claim Got Denied

February 27, 2020

Medicare processes millions of claims per year, and that includes sending back denials. With so many rules and requirements,  claims can be denied for lots of reasons. Knowing why your Medicare claim was denied is important and can give you a better understanding of how to avoid this problem altogether. Here are some common reasons why a Medicare claim may get denied.

Up close photo of a vision test machine

Dental, vision, and hearing exams are all examples of non-covered services.

Non-covered service claimed

Medicare is great and can help cover a lot of services, but unfortunately, there are quite a few it simply doesn’t cover. Things like routine dental, vision, and hearing exams are all examples of non-covered services. Unless they are proven to be medically necessary, Medicare won’t cover them and will deny your claim.

Lack of Proof of Medical Necessity

As we mentioned above, Medicare doesn’t cover anything that isn’t medically necessary to treat. In an effort to try and eliminate doctors phishing for a diagnosis, Medicare requires doctors to prove medical necessity for each service they provide.

But sometimes Medicare doesn’t agree that the service a doctor thinks their patient needs is medically necessary. A service that is often denied is blood work. Doctors can become accustomed to non-Medicare insurance, which will usually cover blood work. So, when they see a Medicare patient, they think routine blood work will be covered. Unfortunately, that isn’t the case, as there needs to be a definitive reason for the blood work to be done.

When the billing goes through, it will often be processed as an ordinary claim. Then you’ll owe 20% of the cost, which you might not be expecting.

Coordination of Benefits Issue

Medicare has a Coordination of Benefits (COB) department that manages claims if you have other insurance, like through an employer. It determines which insurance pays primary and which pays secondary.

When you decide to drop an employer’s coverage and transition to Medicare, the employer should be the one to notify Medicare. However, sometimes the employer won’t transfer this information over correctly, or at all. This issue usually comes about when a patient goes to the doctor for the first time after switching over to Medicare as their primary insurance. The doctor will bill Medicare, but since Medicare thinks it’s still the secondary payer, they deny the claim.

Medicare claim with procedure codes and stethoscope in top right corner of image

Sometimes, the doctor’s billing staff will mess up and code the wrong item. This can lead to your Medicare claim getting denied.

Coding Error

Medicare has an assigned Healthcare Common Procedure Coding System (HCPCS) code for each medical service. Sometimes, the doctor’s billing staff will mess up and code the wrong item. Accidents can happen, but the wrong code could mean that Medicare denies your claim. The Welcome to Medicare visit is a common service affected by coding errors.

The Welcome to Medicare visit is a service that Medicare covers 100% within the first 12 months you have Part B. Sometimes, the code will get screwed up and reflect a normal checkup rather than the wellness visit. This is known as a procedural code error.

We’re Here to Help

Medicare claim denials are no fun and a pain to deal with. If you’re looking for some help understanding and appealing your Medicare claim, let Signature Senior Solutions assist you. We can figure out why your claim got denied, and then work to straighten it out with you. You’re never alone when it comes to understanding Medicare. We are always here to help! Signature Senior Solutions is located in Cave Creek, and services all of Maricopa County and Arizona. If you’re out of state, don’t worry, we have a multi-state license and can serve you too.