Medicare Scare

Sometimes seniors are denied claims and they think there is nothing they can do and they just accept it. However, a denied or partially paid claim can be appealed and nearly half of the appeals are successful and worth the effort…might as well give it a try.

When a Medicare claim is denied or approved for less that full amount, you have 120 days to request a “redetermination” of the decision. The proper form to request is called Medicare Redetermination Request Form (Form CMS-20027) which can be downloaded at (http://www.cms.hhs.gov/cmsforms/downloads/cms20027.pdf) or you can call (800) 633-4227.

The written claim denial that you receive includes instructions on where and how to submit the redetermination form. The claim denial should include an explanation why your claim was denied or only offered partial payment. You need to object the explanation in order to be successful with the appeal. You can ask your doctor to write a letter responding to the points raised in teh denial and explain why your health care is necessary. You include a copy of this letter along with the appeals form and as always, keep a copy for your files.

Common Reasons for Denial

The treatment or prescription is unlikely to cause your health condition to improve is the biggest denial circumstance and is a little vague. Medicare is required to look at your total condition, not just a specific diagnosis or your chance at a full recovery.

There was a citizen who was denied for Lou Gehrig’s disease which is incurable and degenerative. The patient successfully appealed, arguing that with the doctor’s help, that while having a nurse visit the home would not improve the condition, it could slow the progression of the disease and was need to care for various health issues.

Sometimes patients are denied because they may require long term care. You need to point out that Medicare is not limited to treatments that work quickly. As long as your doctor continues to order this treatment for you, Medicare should continue to cover it. Include a letter from your doctor if denied for this circumstance explaining that the treatment is having some positive effect or expressing an optimistic expectation that it will.

There are several other types of denial and you want to be specific to address the denial and use your primary care physician with a letter expressing an opinion that is different that Medicare’s conclusion.

Don’t give up

Sometimes you may have to go to Appeal #2 where you’ll have 180 days from the date your redetermination request is denied. You must completed Medicare Reconsideration Request Form (Form CMS-20033, at www.cms.hhs.gov/cmsforms/downloads/cms20033.pdf). You may have to ask your doctor to write a new letter or attach the old letter. Sometimes it is about hanging in there and being determined.

You may have to take it to Appeal #3 if your second appeal is denied and the amount in dispute is over $120. You have 60 days to file a third appeal, this time with an Administrative Law Judge (ALJ) of the US Dept of Health and Human Services. The filing instructions would be included with the denial letter.

Appeal #4  If the judge turns you down you have 60 days to request that Medicare Appeals Council (MAC) review the decision. The ALJ denial will include instructions on how to file.

Appeal #5 If the MAC turns you down you have 60 days to determine if you wish to hire an attorney and file a judicial review in federal district court. The amount in dispute must be greater than $1,180 to qualify.

I hope this helps a few Seniors and empowers them to fight their fight for benefits.

James Burns, Esq.

www.jamesgburns.com

(949) 440-3243

Credit Card Wars

I’ve been predicting that credit cards would be the next financial branch to go on the offensive for risk management and start closing cards or cutting credit lines.

Indeed, credit card issuers are tightening lending terms with consumers to lower their risk profile, from cutting borrowing limits to closing dormant accounts and I’ve had a few clients already that have fallen victim to this pre-risk practice.

A survey of credit card industry executives in July found that 62 percent of their companies planned to reduce lines of credits because of economic conditions and risk mitigation, according to Javelin Strategy & Research.

While changing a customers credit limit is nothing new, representatives of the largest card issuers in the U.S., Bank of America, JPMorgan Chase and American Express, say they are increasingly cutting credit card limits for their customers because of the downturn and to avoid risk.

American Express routinely changes the credit limit of 20 percent of its customers every year, more cards are being limited or lowered than raised this time around, according to Kim Ford, a spokesperson at the company. This year, only one out of two customers saw an increase, versus four out of five in the recent past and they had excellent credit and payment history.

Ford says it reflects a change in the criteria used to assess riskier customers, factoring in such things as whether the card holder has a subprime mortgage, the geographic location of the home and whether home prices are falling in that area. We can only imagine how they view California right now as the earth drops all the way to China in terms of housing prices.

American Express is not alone. “We’re working more aggressively to control risk,” said Betty Riess a spokesperson at Bank of America , adding the company is also closing accounts of customers that have had a zero balance for over a year and have a riskier profile.

A spokesperson at JPMorgan Chase stated the bank is positioning itself by taking a second look at riskier customers as a result of economic conditions.

Like much of the credit crunch, the changes may mean little to those with the best credit or those who spend and borrow judiciously and pay off their monthly balances. But if you get caught in that financial quicksand, you could go down without a rope and have it adversely affect your credit score.

Accordingly, cutting credit limits or closing accounts can have a negative effect on a consumer’s credit score, or FICO, says Liz Pulliam Weston, a personal finance columnist and author of “Deal with Your Debt.” That’s because one way credit scores are calculated is by looking at the debt-to-available credit ratio. The closer the debt to the credit limit, the lower your credit score.

A credit limit reduction, for instance, can lower your credit score by 30 to 50 points, says Weston.

With lower credit limits, cash-strapped consumers, will have less of a back up— and in some cases none at all—when things get tough.

“It’s going to, in turn, effect discretionary spending,” says Bruce Cundiff, director of payments research and consulting at Javelin Strategy & Research.

What should you do?

Pay Attention

A change in credit lines or account closures will be communicated in writing. Woosley says consumers should check online statements as well as regular mail, as some of the notices can look like junk mail.

“You should know your credit score by checking it at least once a year, says Weston. I like and personally use myfico.com, as it comes from the folks who created FICO and is the most reliable in my opinion.

Appeal The Decision

If you get a notice saying your credit limit is being reduced, you can call up or write the company and try to reverse the decision, especially if you feel your credit score is in good standing. Sometimes, mentioning the possibility of changing card issuers can help. “Consumers still have some power,” says Weston.

Use Your Card

If you have a dormant, or inactive, card—one with a zero balance on a regular basis—use it for small purchases, recommends Kaplan. “It might be a good idea to go out and use it, so it doesn’t look like it’s sitting there unused,” she said.

Don’t Miss Payments

An obvious piece of advice, but worth repeating, try to pay your balance in full every month, avoiding interest and finance charges.

Companies are less likely to take action “if you have good credit,” says Kaplan.

Seek Credit Restoration

We assist consumers with credit restoration so you can contact my office as we’ve been successful in removing derogatory reporting and using the law to ensure that the reports are accurate as it is suprising how many times it is not.

Loan Modification and Foreclosure Avoidance

Usually if there is one financial situation there is another and we can help you get a loan modification that will free you from the bondage of a high interest rate that can totally sink you and your credit and once you’re credit is ruined it takes close to a decade to get it back without help.

James Burns, Esq.