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Health Care & Insurance

Medicare Mistakes That Can Jeopardize Your Claims

Medicare has strict requirements for certain kinds of care, which can lead to claims problems.

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One of the biggest challenges for Medicare beneficiaries is getting coverage for skilled nursing or skilled rehab care. Medicare covers up to 100 days in a skilled nursing facility if you need skilled nursing care seven days a week or skilled rehabilitation services at least five days a week. But to qualify, you must have been an inpatient in a hospital for at least three days. If the hospital classified you as “under observation” rather than as “admitted”—even if you were in the hospital for several days—you won’t meet the standard. (You may not know you weren’t admitted until you get the bills.)

See Also: Guide to Getting the Most Out of Medicare, 2015

To avoid being blindsided, ask the hospital how your stay is categorized while you’re still in the hospital. If your status is “under observation,” work with your doctor to try to get it switched while you’re still there. Some hospitals will resist doing it, perhaps to keep admission days down. Still, they might revise your status if your doctor provides new information.

Kathleen Hogue, a medical claims specialist in Twinsburg, Ohio, knew what questions to ask when the rescue squad took her aunt to the hospital after she fell and injured her neck. At first, the hospital said her aunt was under observation, but after an MRI showed a fracture in her aunt’s neck, Hogue worked with the hospital to change her aunt’s status to admitted.

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The observation designation can also cause confusion with drug coverage. Drugs in the hospital aren’t covered under Medicare Part A if you’re under observation, but they may be covered by Part D if you submit the paperwork.

Coverage restrictions. Certain services are covered by Medicare only in limited circumstances. For example, chiropractic services are covered if medically necessary to correct a subluxation (when the bones of your spine move out of position). “Make sure the service you’re getting is covered by Medicare for the reason you’re getting it,” says Margaret Murphy, of the Center for Medicare Advocacy. If not, you may have to eat the whole cost (remember, medigap supplements only what Medicare already covers). Use the Is My Test, Item or Service Covered? tool on the Medicare.gov site.

Medicare Advantage plans have restrictions similar to those of managed-care plans for people younger than 65. “Understand the rules of the plan if you need referrals or to see someone out of network,” says Casey Schwarz, of the Medicare Rights Center. You may get permission to go to an out-of-network provider if you can prove that the special care is necessary. Patty Shaffer, of Florida SHINE (the State Health Insurance Assistance Program), recently helped the family of a Florida man with cancer who needed emergency treatment while visiting his daughter in New York. The insurer wanted him to return to Florida but changed its decision after Shaffer worked with the man’s doctor and the hospital.

Prescription-drug glitches. Part D insurers may require your doctor to fill out a preauthorization form explaining why you need a specific drug, or they may cover a particular drug only after you’ve tried a list of less-expensive medications. Such steps take time, so don’t delay getting your prescriptions filled, says Denise Sikora, president of DL Health Claim Solutions, in Woodbridge, N.J.

For more help, contact your State Health Insurance Assistance Program (call 800-633-4227 or visit www.shiptacenter.org), or call the Medicare Rights Center (800-333-4114).

See Our Slide Show: 11 Common Medicare Mistakes