Medicare Advantage & ALJ Hearing
Brett
Description
Collection
Title:
Medicare Advantage & ALJ Hearing
Creator:
Brett
Date:
2/6/2014
Text:
Good Morning Everyone,
I participated in an ALJ hearing for a PRIOR AUTHORIZATION yesterday for an prosthesis with an MPK Knee unit. The ALJ hearing was only 6 months from the filing because the BENEFICIARY filed the appeal.
It appears the patient WON the appeal and the Advantage plan will now authorize the prosthesis.
The issue is this…..the patient changed insurance companies, a different Medicare Advantage program, as of January 1st because the original program denied authorization of the prosthesis.
On the surface it would seem they could claim the patient is not currently enrolled and avoid the financial liability. But, if that was the case, all the Advantage programs could do the same with high dollar services, deny authorizations, let the beneficiary change companies before the appeal process runs the course, to avoid the expense.
The other thought is that the original insurance company should be held liable for the prosthesis because the patient would have used it from the time the patient needed it and was covered by the original company, had they not broken the rules in denying legitimate care.
Does anyone have experience with is type of situation? Is there a CMS rule on this to indicate the original insurance will have financial liability for the prostheses?
Brett R. Saunders, CPO, FAAOP
<Email Address Redacted>
761 County Road 466
Lady Lake, FL 32159
(352) 259-9749 Phone
(352) 259-8209 Fax
I participated in an ALJ hearing for a PRIOR AUTHORIZATION yesterday for an prosthesis with an MPK Knee unit. The ALJ hearing was only 6 months from the filing because the BENEFICIARY filed the appeal.
It appears the patient WON the appeal and the Advantage plan will now authorize the prosthesis.
The issue is this…..the patient changed insurance companies, a different Medicare Advantage program, as of January 1st because the original program denied authorization of the prosthesis.
On the surface it would seem they could claim the patient is not currently enrolled and avoid the financial liability. But, if that was the case, all the Advantage programs could do the same with high dollar services, deny authorizations, let the beneficiary change companies before the appeal process runs the course, to avoid the expense.
The other thought is that the original insurance company should be held liable for the prosthesis because the patient would have used it from the time the patient needed it and was covered by the original company, had they not broken the rules in denying legitimate care.
Does anyone have experience with is type of situation? Is there a CMS rule on this to indicate the original insurance will have financial liability for the prostheses?
Brett R. Saunders, CPO, FAAOP
<Email Address Redacted>
761 County Road 466
Lady Lake, FL 32159
(352) 259-9749 Phone
(352) 259-8209 Fax
Citation
Brett, “Medicare Advantage & ALJ Hearing,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 1, 2024, https://library.drfop.org/items/show/236059.
