Any recourse, or is my mom screwed? (Medicare Part D claims)

In My Humble Opinion (IMHO)
#1

My mother has Medicare Part D, which is the plan that pays for prescriptions. Turns out, we were paying full price for her prescriptions all year last year, even though her pharmacy had her Part D information. This was caught by the pharmacist in November. The pharmacy reimbursed us directly for three months of prescriptions and we filed a claim to the insurance company for prescriptions purchased from January through July.

Turns out that you only have three months from date of purchase to file a claim according to the insurance company.

This adds up to around $1700 of over-payment that won’t be covered.

Do we have any recourse, or is mom screwed? Can we appeal to the insurance company? Can we hold the pharmacy liable?

I realize that we should have known, but we didn’t. She takes really expensive medications for Alzheimers. We figured the high cost was just the limits of her policy. I can accept that and learn this painful lesson if there is no recourse. But I don’t want to give up prematurely if there is still means to get her money back.

Thoughts?

#2

Check your mom’s plan’s evidence of coverage (EOC) for written documentation of their policy. Look for manual claims or paper claims - those are generally the after-the-fact requests for reimbursements and that section should tell you how long you can do that. Additionally, you should be able to appeal any coverage determination, so you can call back and tell them that you want to file an appeal, though if the manual claims policy is 90 days, you might not get much further than appeal that way.

However, from what you’ve written, it sounds like it was a pharmacy error. Though the plan is responsible for pharmacies in their network, they’ll probably bounce you back to the pharmacy. If the pharmacy won’t agree to reimburse your mom, I would call 1-800-MEDICARE and file a complaint with them. It’ll still come back to the plan, but when you go through Medicare, it puts more pressure on the plan to fix it, regardless of who’s responsible. I’m not saying that they will fix it, but you should know that plans are rated in part by the number of complaints filed against them through Medicare and their ability to respond to them in a way Medicare feels is appropriate. Most plans are very careful not to piss off beneficiaries enough to contact Medicare.

#3

::sigh of relief::

Thank you, overlyverbose. That helps my frustration level today.