Aug. 1, 2007 -- "Good Morning America" is exploring the American health-care system in an ongoing series called "GMA Gets Answers."
Today, "GMA" looked at the issues many people face when trying to get drugs or medical treatments covered by Medicare.
Here are some tips that lawyers and experts who deal with Medicare regularly say you should know if you find yourself having difficulty getting treatment through Medicare:
Insist your doctor, pharmacist or other medical provider files a claim for the services you receive, even if they do not think Medicare will cover them. Providers often misinterpret Medicare regulations or just assume Medicare will not cover an item. The only official way to know if Medicare will pay for a service is to file a claim. Typically, Medicare will only decide if a drug or treatment is covered after the service is provided and a claim is filed.
If Medicare denies your claim, file an appeal. Medicare insiders say appeals are often decided in favor of the patient. While experts say the appeals process is not always easy, it can provide results.
Whenever possible, get the service or treatment your doctor says is medically necessary. Do not forgo treatment because you think you cannot afford it. Many doctors and pharmacists are willing to wait for payment until after a claim or appeal is filed with Medicare. Negotiate if possible. Delaying treatment or not taking a prescribed medicine will often lead to additional health problems.
If you are having trouble obtaining coverage, enlist the help of your doctor. In some cases, a doctor's support is required to obtain coverage. In most cases, a physician's opinion about treatment is given additional weight. Medicare has support personnel and resources that only doctors can access. Ask your physician to call Medicare, Medicare Advantage or your Medicare Part D plan provider on your behalf.
Ask your physician for any supporting materials in writing. A letter from your doctor explaining why your treatment is medically necessary can be faxed or mailed to a Medicare provider or used in the course of an appeal.
Keep detailed notes of all phone calls you make while trying to get coverage. Write down the names of the people you spoke with, the phone number you called and the time and date of the call. This information can be useful during an appeal. It can also help you get back to the same customer support person, so you do not have to repeat your story each time you call.
If a provider says it will not pay for a treatment or service, ask why. Medicare decides whether or not it will reimburse a service or medicine based on a diagnostic code — a unique identifier assigned to different types of illness and conditions. Because diagnoses are sometimes subjective, doctors can often adjust diagnostic codes in order to assist you in acquiring treatment.
Organizations to Contact for Help
These organizations assist people who are having difficulty getting coverage through Medicare:
Center for Medicare Advocacy
Medicare Rights Center
State Health Insurance Counseling and Assistance Programs (SHIPS) exist in all states and are available to assist patients. Click here for a list of SHIPs.