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Successfully Appealing a Medicare Denial

The first 100 days in a nursing home is a particularly critical time for a spouse or parent transitioning into skilled nursing home care. If the transition into skilled care followed a hospital admission and 3-day hospital stay, Medicare coverage is generally triggered. This can cover a portion of the person's nursing home bills. However, Medicare coverage is often terminated prior to the end of that period, and families should know how to appeal that termination. To start, the resident or responsible family member must receive written notice of termination, and that notice form provides a toll-free number to contact to appeal the decision. Generally, there is a 24-hour time limit for appeal, and families should call immediately to file an appeal. The next step is to contact an attorney knowledgeable in elder law. Previously, Medicare coverage could be terminated prior to 100 days' time if the patient fails to improve or respond to rehabilitative treatment. This is no longer a valid basis for denial, but nursing homes and medical personnel continue to erroneously terminate benefits. Usually, a primary and secondary appeal are necessary, and often a hearing before an ALJ as well. The cost of not appealing can mean thousands of dollars of lost coverage for families.

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