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Medicare Provider Appeals

Our team of attorneys includes a former Medicare attorney who has extensive Medicare audits, overpayment demands, and Medicare appeals. The Medicare appeals process can be a long and truncated process. This is why it is so important to file the initial redetermination request correctly and concisely. Our attorneys assist providers with reimbursement denial re-considerations, administrative hearings, and other regulatory and criminal violations. We also assist with compliance issues, self-audits and health care fraud allegations.

CMS has recently increased its audit process, utilizing private contractors to perform review of previously paid claims and to determine whether reimbursement was proper. In the event the auditor determines that a claim was improperly paid based upon coding errors or lack of medical necessity, a request for reimbursement will be submitted to the provider who has a limited time to properly respond. The failure to formulate a proper response can lead to an investigation by the Office of the Inspector General (OIG) and potential charges under the False Claims Act.

Whether through a reimbursement/recoupment audit or the denial of an initial claim, the Medicare provider appeals process can be a daunting experience. With the various stages of appeals, it is important to have a trusted and experienced health care attorney to guide you through the nuances and pitfalls associated with unpaid Medicare claims. After a claim has been denied or reimbursement has been requested, there are five stages to appeal an initial decision by Medicare:

1. Re-determination by Medicare Administrative Contractor (MAC)
2. Reconsideration by Qualified Independent Contractor (QIC)
3. Administrative Law hearing
4. Medicare Appeals Council review
5. The United States District Court review

Medicare Appeals Process

With a current backlog of 700,000 claims, it is important to pick the right representative to ensure that your claim does not fall through the cracks in the system. Under the first stage, a remittance request must be filed within 120 days from the date of receipt of the initial determination. The request must be in writing, filed by you or your authorized representative, with the claim number, and signed by you or your authorized representative, along with any supporting documentation to prove the validity of the claim. The MAC has 60 days to issue a decision based upon the information that has been provided. A proper response to either a denial of a claim or remittance advice (RA) at the initial stage is crucial in resolving an outstanding dispute and to avoid any interruption in business cash flow.

If the MAC issues an unfavorable decision, the provider then appeals the decision to the QIC within 180 days. This response must again be set out in writing and clearly explain the reason for the disagreement along with any other evidence not included in the initial determination. It is important to note, that evidence not included in the reconsideration request may be excluded from consideration in the further stages of the appellate process. Within 60 days of the submission, the QIC will issue a decision based upon all of the submitted evidence. It is important that this response is prepared by a qualified legal representative to ensure that all the pertinent evidence is submitted and explained in order to achieve a favorable determination.

The Office of Medicare Hearing and Appeals (OMHA) is a division of the U.S. Department of Health and Human Services (HHS) is the administrative law division responsible overseeing appeals of QIC decisions. The administrative law hearing is conducted remotely by video or telephonic means, or in cases where good cause is shown, on an in-person basis. The request for the administrative law hearing must be filed within 60 days of the unfavorable QIC decision and a copy of the hearing request must be sent to all other parties in the QIC process. In order to qualify for a hearing, the amount in controversy for 2016 must be greater than $150. While CMS has proposed an additional level of review before an administrative law hearing through HHAS-2015-49 through a designated Medicare attorney, that proposal has met with staunch criticism and has not yet been implemented.

Within 60 days of the administrative law hearing, a party must request an appeal before the Medicare Appeals Council which has 180 days from receipt to issue a decision. If a decision is not reached within this timeframe, or if the decision is unfavorable, then, and only then, may a party escalates this claim to the U.S. District Court of Appeals. The amount in controversy for District Court review has risen in 2016 to $1,500.

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