Medicare Appeals

The five-level process for challenging a Medicare denial - of a claim, a service, a hospital discharge, or a nursing-home stay - with a different deadline at each level and a fast track when the care is about to stop.

Looking for a lawyer rather than a definition? Skip to the state-by-state list of Health Care law firms.

What it means

A Medicare beneficiary who is denied coverage - a claim paid at nothing, a service refused as not medically necessary, a drug excluded, a skilled-nursing stay cut off - has a right to appeal, and the process has five levels. The first is a redetermination by the contractor that made the decision (or, in Medicare Advantage and Part D, a reconsideration by the plan). The second is an independent review by a qualified independent contractor or independent review entity. The third is a hearing before an administrative law judge, available if the amount in dispute meets a threshold adjusted annually. The fourth is review by the Medicare Appeals Council, and the fifth is a civil action in federal district court, again subject to an amount-in-controversy threshold. Each level has its own filing deadline set by regulation, and missing one ends the appeal unless good cause is shown.

Two fast tracks exist for care that is about to end, and they are the ones a family is most likely to need at short notice. A hospital inpatient who receives a discharge notice may ask the Beneficiary and Family Centered Care Quality Improvement Organization for an immediate review, and if the request is made by the deadline on the notice the patient is not liable for the continued stay while the review is pending. The same expedited review is available when a skilled-nursing facility, home-health agency, hospice or rehabilitation facility issues a notice that Medicare coverage is ending. In Medicare Advantage, a plan must decide an expedited pre-service appeal within a short period where the standard timeframe could seriously jeopardize the patient's health.

Two systemic issues account for many appeals. "Observation status" - a hospital keeping a patient for days without formally admitting them - means the stay does not count toward the inpatient stay that Medicare requires before it will cover a skilled-nursing facility, and a federal court settlement now allows some patients to appeal that classification. And the "improvement standard", under which providers told patients that skilled care would end because they were not getting better, was disavowed in a federal settlement: coverage depends on the need for skilled care to maintain or slow the decline of a condition, not on improvement.

Where this comes from

When people hire a lawyer for this

The first two levels are designed to be used without a lawyer, and the State Health Insurance Assistance Program in every state helps beneficiaries with them at no charge. The situations that justify paying for advice are a discharge or termination notice with the deadline running today, a denial involving a large or ongoing cost such as a skilled-nursing stay, and anything reaching the administrative law judge level, where the case is argued on medical necessity and the record needs a treating physician's letter and the plan's own coverage criteria.

Worried about the cost? A lawyer can be hired for one part of a case only (limited-scope representation), may be paid from what a claim recovers (contingency fee), or may be free through a pro bono program or legal aid; a court can also waive its own filing fees.

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Related terms

Other entries in the same area of law, each written from the same primary sources.

• Advance Directive and Living WillDocuments recording medical treatment wishes, and naming who decides, if a person becomes unable to decide for themselves.
• Civil Commitment (Involuntary Psychiatric Hospitalization)The state-law process by which a person can be held and treated in a psychiatric facility against their will - the emergency hold, the court hearing, the standard of dangerousness, and the constitutional limits on all three.
• COBRA Continuation CoverageThe federal right to stay on an employer's group health plan after leaving the job, losing hours, divorcing, or a covered employee's death - at the full premium, for a limited period, if elected in time.
• Elder Abuse and Adult Protective ServicesWhat the law counts as abuse, neglect or exploitation of an older or dependent adult, who must report it, what Adult Protective Services can and cannot do, and the civil and criminal remedies that follow.
• EMTALA (Emergency Medical Treatment and Labor Act)The federal law that requires a hospital emergency department to screen and stabilize anyone who comes through the door, regardless of insurance or ability to pay, before it may transfer or discharge them.
• Fair Hearing (Public Benefits)The hearing you are entitled to before benefits such as Medicaid or SNAP are cut off or denied - a constitutional right, not an agency courtesy.
• False Claims Act and Health Care Whistleblowers (Qui Tam)The federal statute under which false billing to Medicare or Medicaid carries treble damages and per-claim penalties, and the qui tam procedure that lets a private person sue in the government's name and share the recovery.
• Health Plan Claim Denial and AppealThe structured process for challenging a refusal to cover treatment - internal appeal first, then in most cases an independent external review.
• HIPAA and Your Medical RecordsThe federal privacy rules for health information - including a right to get a copy of your own records, which is narrower and more practical than the privacy rule people usually mean.
• Hospital Financial Assistance and Medical DebtThe federal rules that make a nonprofit hospital publish a financial assistance policy, limit what it may charge eligible patients, and restrict how it collects - and what a patient with a medical bill can do with them.
• Informed ConsentA patient's agreement to treatment after being told the risks and alternatives - and a signed form is evidence that the conversation happened, not proof that it was adequate.
• Life Insurance Claim DenialThe common reasons life insurers deny or delay death benefits, how the rules differ for employer group policies under ERISA, and what beneficiaries can do about disputes over who gets paid.
• Medicaid Estate RecoveryThe federal requirement that a state recover the cost of long-term care Medicaid paid for from the estate of the person who received it after they die - the reason the family home is at stake, and the exemptions and hardship rules that limit it.
• Medical Malpractice and the Standard of CareA negligence claim against a healthcare provider, judged against what a reasonably competent practitioner in the same field would have done.
• Mental Health ParityThe federal requirement that a health plan covering mental-health or substance-use treatment cover it on terms no more restrictive than its medical and surgical coverage - in dollars, in visit limits, and in the prior-authorization and network rules that are harder to see.
• Nursing Home Residents' RightsThe federal bill of rights every Medicare- or Medicaid-certified nursing home must honor - dignity, choice, freedom from restraints and abuse, notice before transfer or discharge - and the inspection and complaint system that enforces it.
• Patient AbandonmentWhen a physician or provider may end a relationship with a patient, what notice and transition care they must give, and when ending it - or refusing to start it - becomes actionable.
• Psychotherapist-Patient PrivilegeThe rule that keeps what a patient tells a therapist out of court - who it covers, who holds it, how it is waived, and the duty-to-warn and child-abuse exceptions that override it.
• Refusing Medical TreatmentThe right of a competent adult to refuse any treatment, including one that keeps them alive; what happens when the patient cannot decide; and the limits the law places on it.
• Social Security Disability Appeal (SSDI and SSI)The four-step process for challenging a denied disability claim - and most claims are denied at the first step.
• Stark Law and the Anti-Kickback StatuteThe two federal laws that govern financial relationships in health care - the strict-liability ban on physician self-referral and the criminal ban on paying for referrals - and why nearly every practice arrangement has to fit an exception or a safe harbor.
• SubrogationThe right of an insurer or health plan that paid your bills to be repaid out of your settlement - the reason a recovery is often smaller than it looks.
• Supplemental Security Income (SSI)The federal needs-based benefit for people who are aged, blind or disabled and have little income or savings: how it differs from Social Security disability, what counts against it, and how to appeal.
• Surprise Medical Billing (No Surprises Act)The federal protection, since 2022, against a bill from an out-of-network provider the patient did not choose - the emergency room, the anesthesiologist at an in-network hospital, the air ambulance - and the good-faith estimate an uninsured patient can hold a provider to.
• Surrogate Decision-Maker (Default Surrogate Laws)Who makes medical decisions for a patient who cannot and who never named anyone - the ranked list most state laws supply, the standard the surrogate must apply, and what a surrogate cannot do.
• Veterans Disability CompensationThe tax-free monthly VA benefit for disabilities connected to military service: what service connection means, how ratings work, and the three ways to challenge a VA decision.

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