Health Law | Medicare Appeals
Pennsylvania Health Law Firm
The Martin Law Firm is a health law firm located in Blue Bell, Pennsylvania. Attorney Jason B. Martin is an experienced health care attorney who represents health care providers facing a Medicare audit. Medicare audits are extremely challenging for health care providers, and it is important to have an attorney with expertise on your side to help navigate through the Medicare appeals process.
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The Medicare Appeals Process
When a health care provider receives a determination from Medicare that previously paid claims are denied, the health care provider may appeal the determination. Federal law establishes an appeal process for Medicare claims. There are five (5) levels of appeal: Redetermination, Reconsideration, Administrative Law Judge, Medicare Appeals Council and Judicial Review in Federal Court.
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Redetermination. The health care provider may file a Level 1 appeal within 120 days of the receipt of the initial demand letter. The Level 1 appeal goes to the provider's claim processing contractor. The contractor has 60 days to send the redetermination to the provider. The provider may present new evidence during this stage. It is important to note that a provider may request a stay of the recoupment at this stage if the provider submits an appeal within 30 days of the receipt of the demand letter.
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Reconsideration. If the first-level appeal is unsuccessful, the provider may request reconsideration by a QIC (Qualified Independent Contractor) within 180 calendar days of the receipt date of the notice of an unfavorable determination decision. This appeal is an independent review, and it is extremely important to submit all new evidence at this stage of appeal, as this is the last stage that allows providers to submit new evidence. The provider may continue to stay recoupment if the reconsideration is filed within 60 days of receipt of the unfavorable redetermination decision. A QIC is required to issue its decision in writing within 60 calendar days of receiving the request for reconsideration, including the basis for an unfavorable finding. For denials based on the lack of medical necessity, the QIC's reconsideration involves a panel of medical professionals who make a decision based on their clinical experience, the patient's medical records and any medical, technical and/or scientific evidence contained in the record.
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Administrative Law Judge (ALJ). An ALJ hearing request may be filed for any claim decided by a QIC. The request must be filed by the health care provider within 60 days from the receipt date of the QIC's reconsideration decision. The ALJ must issue a decision on the appeal within 90 calendar days of receipt of the request for a hearing and explain any unfavorable findings. For ALJ hearings, the provider has the option of providing oral testimony through video, telephone or an in-person hearing, which may involve the provider, legal counsel, clinical experts and any other participants arranged by the provider.
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Medicare Appeals Council. A review by the Medicare Appeals Council may be initiated in one of three ways. First, following the receipt of an unfavorable ALJ decision, a provider may file a request for Medical Appeals Council review within 60 calendar days in order to continue the appeals process. The Medicare Appeals Council must accept all provider requests for review and issue a decision, which should explain any unfavorable findings, within 90 days. Second, CMS may request Appeals Council review within 60 days of receipt of the ALJ decision, although the Council may decline CMS' request. A Medicare Appeals Council review that is made upon CMS' request also must be decided within 90 days of the ALJ decision. Finally, the Medicare Appeals Council may, on its own motion, elect to review an ALJ's decision on a claim, which must be initiated within 60 days of the ALJ decision and decided within 90 days. The Medicare Appeals Council generally does not hold an evidentiary hearing and instead bases its decision on the administrative record of the case, including the recording of the oral testimony before the ALJ.
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Judicial Review in Federal Court. A health care provider has 60 days from the receipt of the Medicare Appeals Council decision to file a request for judicial review with the relevant federal district court.
Rebuttals
In addition to the appeals process, a rebuttal option is available for the first three levels of the appeals process and is administered by the claims processing contractors. To initiate a rebuttal, the provider issues a written statement to its primary claims contractor within 15 days of the date of the written notification of the review outcome. The rebuttal is the provider's written explanation of why the recovery of a denied claim should not proceed. A rebuttal does not affect or delay the time frame of the formal appeals process and is not a substitute for filing an appeal. Many providers use the rebuttal process simultaneously to preparing an appeal to ensure compliance with the appeals deadlines.
This summary provides a general overview of the Medicare audit and appeals process. It is extremely important for the health care provider to contact an attorney once Medicare begins the medical review process. An experienced health care attorney can help the provider understand the process and begin preparing an appropriate defense to an adverse determination and recoupment.
Contact a Health Care Attorney at the Martin Law Firm
Successful appeals usually occur only after a diligent review of the records, consultation with attorneys and other health care experts and careful attention to the details at each stage of the appeals process. The Martin Law Firm has assisted providers with Medicare audits and appeals and has reached successful outcomes for clients located throughout the United States.
Contact an experienced health care attorney at the Martin Law Firm for a free case evaluation.
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