Medicare has terminated your coverage for a physical therapist, nurse or speech therapist. The health care provider states that you have “plateaued” , ‘have not improved” or require “maintenance services” only. In addition, the health care provider states that you must pay out of pocket if you want to continue these services. However, you and your physician opine that you need these services and that they are medically necessary. So what should you do? Appeal Medicare’s decision.
The initial document you will receive before termination is a “Notice of Medicare Provider Non-Coverage” or a” Generic Notice” from your health care provider. When you receive this notice, immediately call the Beneficiary and Family-Centered Care Quality Improvement Organization, or BFCC-QIO. The phone number will be on the notice that you have received. Fax to them a written opinion by your physician that the services are “medically necessary” and that your health will be jeopardized if services are dis continued. In addition, have the health provider deliver your records to BFCC-QIO and a copy to you.
The BFCC-QIO must make a decision within 72 hours of receipt of your appeal. If they agree with you coverage will be continued, if they don’t then you have to pay out of pocket for those services.
If the BFCC-QIO denies your appeal, call the agency and request an “Expedited Reconsideration” by no later than Noon on the day after receiving the denial. The agency must render a decision within 72 hours of receipt of your phone call.
If you receive another denial, you can then have a formal hearing in front of an Administrative Law Judge. At this hearing you will personally submit your evidence as will the BFCC-QIO.
Remember, throughout this appeal process you are financially responsible for any continued services.
In our next blog post we will discuss the “Myth of Having to Show Improvement” in order to maintain Medicare coverage.