Why Does Medicare Deny Claims?

[beachbum2012]

I'm just starting my 3rd year in the Medicare supplement business so I'm starting to run into more questions from clients about bills and what not. Several clients I've talked to recently have had routine, "medically necessary" tests and treatments done that Medicare has denied.

For example, one of my clients got bit in the face twice by her daughter's cat. Throughout the day, her face continued to swell and get more red, obvious that it was infected. She went to urgent care and got treated, but she got billed for a tetanus shot and another vaccine because Medicare didn't cover it. It wasn't a bill because she hadn't met her deductible either.

I thought Medicare was supposed to cover medically necessary things. I mean if a doctor is ordering blood work or an urgent care facility is giving vaccinations, aren't these necessary? What's typically the best course of action in these spots? Have the facility re-submit the bill to Medicare, maybe with a different code? File an appeal with Medicare? Any other suggestions?

 

[yogooglethis]

I'm just starting my 3rd year in the Medicare supplement business so I'm starting to run into more questions from clients about bills and what not. Several clients I've talked to recently have had routine, "medically necessary" tests and treatments done that Medicare has denied.

For example, one of my clients got bit in the face twice by her daughter's cat. Throughout the day, her face continued to swell and get more red, obvious that it was infected. She went to urgent care and got treated, but she got billed for a tetanus shot and another vaccine because Medicare didn't cover it. It wasn't a bill because she hadn't met her deductible either.

I thought Medicare was supposed to cover medically necessary things. I mean if a doctor is ordering blood work or an urgent care facility is giving vaccinations, aren't these necessary? What's typically the best course of action in these spots? Have the facility re-submit the bill to Medicare, maybe with a different code? File an appeal with Medicare? Any other suggestions?

Medicare covers the cost of the administering the shot under part B but the vaccines such as tetanus,shingles etc. are considered outpatient drugs and should be covered under part D usually at a tier 4 co pay.

Medicare stopped covering the cost of most vaccines under part B about 3 or 4 years ago.