We have been seeing some MEDICARE cases where an appeal or review or fair hearing was not requested because "the patient was not covered anyway". In one instance, where the treatment was TPN for inability to digest food. The doctor's certificate of medical necessity stated that the treatment was for 6 months. MEDICARE requires permanent impairment of the digestive system, and the regulations state that permanent impairment usually means at least 3 months duration.

In one case we saw recently, the doctor's CMN said the TPN treatment duration was 6 months. The reimbursement specialist failed to ask for review, saying that it was not covered by MEDICARE. In fact, it was covered, because the doctor had prescribed the TPN for six months. This is doubly serious because many health plans refuse to pay if MEDICARE does not pay, as was true in this case. Yet MEDICARE should have paid, and the insurance carrier should have paid its 20%. Instead, MEDICARE did not pay, and the insurance carrier did not pay.

Our office recommends that each MEDICARE denial must be appealed, or review requested, immediately. The reimbursement specialist usually is not an attorney, and does not know the regulations, although they may have some familiarity. The regulations are complicated, and many attorneys are not familiar with the regulations. The reimbursement specialists should not take it upon themselves to interpret the regulations. Failure to heed this can be very expensive for a provider.