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. To find out more on what you can do go to: What is the Process for Medicare Claims and Appeals (mirzahealthlaw.com)
