Recent Increase in Denial of Medicare Coverage

With quarter three of MMSEA Section 111 reporting for workers’ compensation and no-fault (as well as liability claims with ORM) underway, it appears that the transparency of claims to Medicare has resulted in the denial of coverage to an increasing number of Medicare beneficiaries. Denial of coverage can be very frustrating to a Medicare beneficiary, particularly if the denial is improper. However, the Medicare beneficiary is not without recourse as Medicare has an appeals process that the beneficiary can pursue if they feel that Medicare improperly denied coverage.

Insurance carriers, employers or third-party administrators may be contacted by Medicare beneficiaries who have been denied coverage. When these situations arise it is important to obtain as much information as possible regarding the denial of benefits, such as whether the beneficiary is being denied benefits that are related to a workers’ compensation, liability, or no-fault injury or if the denial is specific to unrelated conditions. It is also important to consider whether there is ORM related to the claim, whether a settlement agreement has been reached and finalized, as well as how the claim was reported to CMS (Section 111 or self-reported).


The denial of coverage may fall in one of the below scenarios:

Beneficiary is being denied medical treatment unrelated to a workers’ compensation, liability, or no-fault claim.

  • On many occasions bills are improperly submitted by medical providers. Billing forms must clearly indicate whether an injury is related to a workers’ compensation claim or other accident (i.e., automobile accident). If the bill erroneously documents the treatment as being related to a workers’ compensation/other insurance claim or is not supplied at all, Medicare may deny coverage until the bill is resubmitted properly. 
  • If inappropriate, incorrect or vague diagnoses codes were provided via Section 111 reporting, the RRE should coordinate with their reporting agent and/or TPA to ensure the proper codes are submitted during the next reporting cycle.
    • For example, CMS allows the use of ICD-9 code 959.9 (other and unspecified injury to unspecified site) for Section 111 reporting purposes. However it is highly likely that this diagnosis code will not provide enough information for Medicare to properly coordinate benefits and additional information will need to be provided. 
    • CMS has stressed on numerous Section 111 teleconferences that RREs should be gathering and submitting the most specific ICD-9 codes as they relate to the beneficiary’s claim. More general ICD-9 codes could leave room for uncertainty during the recovery process.
    • It is important to note that Section 111 reporting is done once every quarter, so updated ICD-9 information may not be submitted immediately. If this occurs, the beneficiary should contact CMS directly to verify what information can be provided to obtain proper coverage for treatment that is immediately required.
  • The claim was self-reported directly to the COBC by the claimant, their representative or insurance carrier and it is determined that inappropriate or incorrect diagnoses were provided which is causing the denial of benefits. The beneficiary will need to work with their attorney or claims representative to provide the appropriate information to CMS and the MSPRC. PMSI may be able to provide assistance on these cases if we are already working with the MSPRC in reference to the claim and have the appropriate forms/releases on file.

Beneficiary is being denied benefits related to a workers’ compensation, liability or no-fault claim.

  • As required by the MSP Act, Medicare is the secondary payer when a primary payer exists, such as a workers’ compensation, liability (including self insurance) or no-fault plan. If a settlement agreement has been finalized, the beneficiary may be responsible for exhausting Medicare Set-Aside funds (or other medical funds designated in the settlement agreement) to cover their future medical expenses which would otherwise be paid by Medicare.
  • At the time of settlement it is important to advise the claimant of their obligation to protect Medicare’s interest regarding past and future medical expenses. When a Medicare beneficiary is denied coverage, they should work closely with their attorney or claims representative to obtain all necessary and proper documentation regarding their settlement agreement and MSA which may be required by CMS or the MSPRC.

Appeals Process
If correct diagnoses codes were provided to Medicare and coverage is denied for conditions which are not related to the workers’ compensation, liability or no-fault claim, the beneficiary must follow the appropriate appeal process. An appeal can be filed if Medicare or the Medicare plan stops providing/paying for all or part of an item/service or if a request for a health care service, supply, or prescription is denied. If the beneficiary wishes to file an appeal, documentation should be obtained from the applicable health care provider, supplier and/or the insurance carrier or TPA handling the claim as needed.

The appeal process will differ based on the type of coverage the beneficiary has (original Medicare coverage, a Medicare plan and/or a Medicare prescription drug plan). Below are the five levels of appeal for Medicare Part A, B and D plans.

  1. Redetermination: Further examination of a claim by personnel different from those who made the initial determination. The beneficiary has 120 days from the initial claim determination to file an appeal. A decision is typically issued within 60 days from receipt of the redetermination request. 
  2. Reconsideration: Can be requested when the beneficiary is dissatisfied with the redetermination outcome and must be submitted in writing within 180 days of the redetermination. Again, a decision is usually rendered within 60 days from the request of reconsideration. 
  3. Administrative Law Judge (ALJ) Hearing: A request for a hearing must be received within 60 days of receipt of the reconsideration. An ALJ will generally issue a decision within 90 days of receipt of the hearing request. 
  4. Appeals Council Review: Request must be made within 60 days of the ALJ’s decision and the Appeals Council will typically issue a decision within 90 days of receipt of the request. 
  5. Judicial Review in U.S. District Court: If there is dissatisfaction with the Appeals Council’s decision, a judicial review before U.S. District Court may be requested. The request must be submitted within 60 days of the Appeals Council’s decision.

For additional information and the appropriate documents/forms concerning Medicare appeals and grievances, visit the official Medicare website.  For additional information concerning the separate levels of the appeal process, visit the Department of Health and Human Services’ website.

In summary, while Section 111 reporting was created to assist in the recovery process, it is not without bumps in the road which may necessitate attorneys and claims representatives to provide assistance to claimants on these matters. It is expected that everyone involved in the process will continue to learn to navigate the somewhat cumbersome—and at times complex—process that CMS has in place for coordination of benefits.

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