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David McGill Blogger

Medicare Coverage Basics

Posted by David McGill | May 19, 2015

While you might dismiss it as too obvious or basic to review, Medicare's "Items and Services That Are Not Covered Under the Medicare Program" brochure provides a comprehensive overview of the topic that is worth reviewing.
Here are the most important things you need to know from this 24-page brochure:
  1. ​Medicare identifies 4 broad categories of non-covered items/services: (a) not medically reasonable and necessary; (b) non-covered items/services; (c) services/supplies denied as bundled or included in another service's allowance; and (d) items/services ​reimbursable by other organizations or furnished without charge.
  2. Non-covered services/supplies include those that are investigational.

​What does this mean for you?

Two takeaways from the brochure -
First, you should be familiar with the 4 non-covered categories of items/services. While this is "Medicare 101," reviewing the basics from time to time is worth your time.
Second, the brochure explicitly confirms that Medicare does not pay for investigational care/treatment. You should use this fact - and by extension, this brochure as an exhibit - when appealing claims that private insurers have denied on the ground that an item is experimental and investigational. The argument is simple: while [private insurance company name] declares this device investigational, the U.S. government (Medicare) has paid for this technology since [insert date]. Since Medicare does not pay for investigational devices, [private insurance company name's] designation of this item as investigational rings hollow."
While the argument in the previous paragraph is not an "automatic winner," particularly when going through the private payer's internal appeal process, it does carry weight, particularly when you appeal to an external review agency.
The moral of this story? Reviewing the basics every so often can help you identify potentially useful arguments and theories that are not so basic.
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