By Jack Cohen
I’ve been married to my wife Ilene for 49 years. She’s a lot healthier than I am. Longevity in her family is amazing. That is why I was so shocked when we received a notice of denial of payment for her annual physical, resulting in a $400 bill.
She is part of the Medicare Advantage Plan and is Medicare eligible. The reason we were given for the denial was “The maximum benefit has been exhausted.” We received this a month after her exam, which she had on August 13, 2015. She had only filed a total of six claims for medical visits during the first eight months of 2015, of which our insurance paid $436.95, or 19.2%, of what was submitted. How could that possibly be exhausting the maximum benefit?
The denial came with instructions on how to file an appeal through various insurance companies and our appeal ultimately became an appeal to Medicare. I supplied all supporting documentation on each visit placed where a claim was filed in 2015.
On December 3rd I received notice that the denial had been reversed and I would be refunded the payment I had made. I received that payment on December 24th…Merry Christmas.
It turns out the issue was that the annual physical must not occur within the calendar year after the last physical. My wife had actually taken her physical one week earlier in August 2014 than she did in August 2015, meaning it was not within a calendar year!
The problem was that the provider somehow transposed it to show that she had taken the 2015 physical earlier than she actually did. The takeaway is that if you are one day short of a full calendar year, you likewise are in jeopardy of “exhausting your maximum benefit.”
One full year must pass before taking your physical, which really means “one year plus.” It is no longer an annual physical. It becomes an “annual plus” physical.
The moral of the story is that we should never take these denials at face value. If you maintain good records and appropriately challenge the denial, you can win.
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