What is the Process for Medicare Claims and Appeals to Collect Receivables

Collecting from Medicare is not easy and often unnecessarily delayed.  Center for Medicare and Medicaid Services (CMS) contracts with private organizations to assist in the administration of the Medicare program by processing and paying Medicare claims. 

Medicare Claims, Reimbursement and Appeals

A standardized claim form like the CMS 1500 or the CMS 1450 (UB-04) are part of the Medicare program and they generally are broad enough that if they are complied with, it typically means that the claim was likely be a clean claim. Florida Statute 641.3155 also defines rules for prompt payment for Clean Claims. 

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.

We are a Florida based business and healthcare law firm focused on enhancing and protecting revenue for healthcare providers, and we will handle US Federal - Medicare issues nationally on a CONTINGENCY FEE BASIS. Our focus includes helping healthcare providers succeed financially so that they can remain focused on their job of delivering care.

Pitfalls in the Medicare Claims Appeal process:

One: Administrative Law is extremely complex and difficult to navigate

Medicare rules in general, and the appeals process in particular, are codified in a complex body of regulations known as administrative law. However, many healthcare providers rely on non-lawyers, typically billing professionals, to file their Medicare appeals. This approach to tackling appeals often creates substantial risks for many providers, as the foundation of any successful appeal is a thorough understanding of the procedural and substantive rules that make up the appeal process.

There are five levels of a Medicare appeal: (1) redetermination, (2) reconsideration, (3) hearing, (4) review, and finally (5) judicial review in federal district court. Each level of the appeal process has its own requirements and time limits for filing. Failure to satisfy these requirements, such as missing an appropriate deadline, can extinguish future appeal rights. Furthermore, presenting inadequate arguments or insufficient evidence at various stages of the process may prevent the introduction of evidence at later stages of the appeal process. 

Two: It is imprudent to rely solely on the person or entity that made the original billing error to conduct the appeal

During a Medicare audit, contractors will attempt to recover funds paid by federal healthcare programs to providers that resulted from billing errors. It does not follow logic to allow the billing company that made the original errors to attempt to defend those errors in the appeals process without oversight or assistance by a qualified attorney. 

Three: Medicare fraud is a crime and the penalties for abuse can be significant

Medicare enforcement is on the rise. The federal government has a variety of contractors and task forces that are aggressively pursuing Medicare fraud, waste, and abuse. While fiscal year 2016 numbers have not yet been released, the government's efforts to combat health care fraud resulted in a recovery of $2.2 billion in fiscal year 2020 and $64 billion since 1986. Some Medicare contractors are paid “bounties” based on the overpayments that they recover, incentivizing a strict culture of review.

What many providers fail to recognize is that errors committed in billing professionals are the responsibility of the provider. There is a misconception that reliance on a third-party billing company immunizes a provider from penalties. However, no matter who is tasked with coding and submitting claims, the responsibility for the claim remains with the provider. It is in the provider's best interest to rely on a qualified healthcare attorney to represent them in these matters.

Let Us Handle Your Medicare Issues

For purposes of Medicare Reimbursement Appeals, our law firm assists physicians, medical practice groups, geriatric care businesses, rehab facilities, healthcare professionals, pharmacies, and other healthcare businesses in business matters, including Medicare and reimbursement issues. Our goal as a law firm is to advance the financial interests of healthcare providers. Too often, providers assume that a claim denied cannot be successfully challenged in a cost-effective manner. Talk to us before you assume that.

We Protect Your Revenue Stream

Earned reimbursement is yours. The delivery of healthcare products and services is challenging enough without losing valuable revenue due to administrative mistakes, oversight, misinterpretations, or misunderstandings about how care has been delivered or documented. Advocating on your behalf – to protect your money – is our business. Let us help.

To put Ben's team to work for you, contact our team directly by Cell/Text at 954-634-2370, or email Ben at [email protected]

Ben Mirza is not only an attorney but was formerly a CPA, with a masters of public health.  There are over 100,000 attorneys in Florida, less than 500 of whom were ever Certified Public Accountants, and even less have the trifecta combination of law/finance/strategic healthcare background.   The benefit of this combined and layered skillset works well for clients who want an advocate to approach the issues holistically.  

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