How The Medicare Appeals Process Works
The Government engages private contractors to process your submission of a Medicare claim. You will receive a Medicare Summary Notice (MSN) that will inform you whether Medicare will pay the claim. The MSN states Medicare's initial “determination” (its payment decision) as to the claim. If the determination is adverse, you can request “redetermination” within the applicable deadline, which is the first of five potential stages in the appeals process as to Medicare's denial of a claim.
Although many appeals can be handled by your inhouse staff, when financial stakes are substantive, involving a legal counsel and/or a qualified consultant early in the process to ensure that all appeals steps are properly taken and documented to fully protect the financial interests of your medical practice or healthcare business. Our law firm will work with top-flight consultants on Medicare appeals to ensure our clients' financial interests and billing methodologies are properly protected and vindicated. Before you write off the claim as a loss, let us review it for you.
Generally speaking, there are five potential stages of a provider's appeal of Medicare's denial of a claim. Each step is different and involves important deadlines and mechanics to properly preserve appeal rights.
1. Redetermination by a CMS Contractor
Your MSN will include instructions for a level one appeal. A request for redetermination is done via paper (i.e., no physical appearance is required). The entity contracted by Medicare to make the initial determination essentially reconsiders its determination based on a purportedly “independent” review. The deadline for filing the request for redetermination is 120 days after receipt of the MSN.
2. Reconsideration of Qualified Independent Contractor
After the redetermination, you may appeal to the contractor's decision to a Qualified Independent Review Contractor (QIC). The deadline for this appeal stage is 180 days from receipt of the redetermination decision.
3. Hearing Before an Administrative Law Judge
The third potential stage of a Medicare Appeal is a request for a hearing before an Administrative Law Judge (ALJ), which is submitted to the Office of Medicare Hearings and Appeals (OMHA). The deadline for this appeal stage is 60 days following the QIC's decision. The hearing may be in person or “on-the-record” (without a live hearing) if the ALJ determines that evidence supports the appeal. Witnesses may be presented at the hearing. For example, you may call an expert or medical professional to testify in support of the appeal. The hearing is recorded and testimony is sworn. A lawyer should be employed to conduct an ALJ hearing.
4. Review of the Appeals Council
The fourth potential stage of a Medicare Appeal is the Medicare Appeals Council (MAC). The deadline for this stage of appeal is 60 days from the ALJ decision. The MAC reviews the record independently of the QIC and ALJ. A lawyer should be employed to conduct this stage of a Medicare appeal.
5. Litigation - A Judicial Review By a Federal US District Court
An adverse MAC decision can be appealed by filing suit in United States District Court if the amount in controversy is at least $1,350 (as of 2012). The lawsuit must be filed within 60 days of the MAC decision. This is formal litigation in federal court and, therefore, without exception, an experienced litigator should be engaged to represent you at this stage of a Medicare appeal.
To find out more about what can be done and what pitfalls lie ahead go to: What is the Process for Medicare Claims and Appeals (mirzahealthlaw.com)
