COLUMBIA, S.C. – There is a way to appeal denials from Medicare Advantage Plans (MAPs), but it requires some creative thinking. Contracted DME suppliers know Medicare Advantage Plans (MAPs) hold all the cards in the appeals process. Suppliers can challenge initial denials through the internal reconsideration process, but doing so often dead-ends with the MAP upholding its original decision.
Contracted suppliers are bound by the confines of their contracts and do not have access to the CMS-designated Independent Review Entity (IRE). However, the patients’ rights are not similarly bound.
Supplier Contracts Do Not Limit Beneficiary Rights
Network contracts stipulate specific remedies, so contracted suppliers cannot appeal as suppliers. Beneficiaries, on the other hand, have the right to appoint an individual to act on their behalf.
Federal guidelines do not preclude beneficiaries from appointing in-network suppliers as their representatives. For a contracted supplier, that means an upheld MAP denial does not necessarily have to stop at the plan level.
The supplier may be able to pursue the case with the IRE on the customer’s behalf. The supplier’s knowledge of reimbursement governance and the patient’s circumstances make them ideal representatives.
Appointing the Representative
Appointment is a patient decision that must be documented carefully using Form CMS-1696.
Required elements include:
1) customer demographics and signature;
2) the representative’s information and signature;
3) a waiver of any fees for acting as the representative; and
4) a waiver of patient payment liability if appeals fail.
Those last two are important. The representative cannot charge any fees for the service of being a representative, and the supplier waives all rights to collection if the denials are ultimately upheld.
Balance billing is not permitted. The supplier must accept the economic consequences of unsuccessful appeals, and the decision should be made in the context of all available options.
Check out the June 2026 episode of (K)notes (00:32:23) for step-by-step instructions for completing CMS-1696.
Representatives are Individuals
The named representative must be an individual, not the DME company. Suppliers should select someone who is likely to remain with the company throughout the appeal lifecycle.
This pathway may not be suitable for every MAP denial, patient, or plan. It can, however, solidify the patient’s rights beyond those of their contracted supplier and reintroduce an element of independent judgment to the appeals process.
Andrea Stark co-founded MiraVista LLC in 2003. She specializes in helping DME suppliers build reimbursement mastery within their organizations through online courses, custom training, direct staff support, and data-driven operational consulting.