When a Medicare contractor denies a claim, the provider generally has a right to a lengthy appeal process, which is both complex and contains many strict deadlines. In some circumstances, claims can take years to fully progress through the appeals process. However, some limited cases may be eligible for settlement depending on the circumstances at hand.
The federal agency that oversees Medicare, the Centers for Medicare & Medicaid Services (CMS), performs few audits itself. In most cases, they outsource these audits to a series of independent contractors, such as Medicare Administrative Contractors (MACs), Recovery Audit Contractors (RACs), Unified Program Integrity Contractors (UPICs), and the Supplemental Medical Review Contractor (SRMC). Most audits are performed by these contractors, although they will often use CMS’s name or logo in their correspondence and may answer phone calls by saying that they are “with Medicare.”
A healthcare provider has options when responding to Medicare audits from the very beginning. Sometimes providers receive Additional Document Requests (ADRs) from the contractor demanding information or documentation to support the claims. These requests must be reviewed carefully. However, it is important to note that they often contain generic language that makes it difficult to determine which specific documents the contractor is requesting. Once the contractor reviews the additional documentation supplied, the contractor will issue its audit findings and determine whether to deny certain claims. Other times, the contractor will audit claims data or other information and issue audit findings without requesting additional information from the provider.
Once a claim has been denied, the first level of appeal is Redetermination. This is often an appeal to the same contractor that made the initial denial. In terms of deadlines, a provider generally must request a Redetermination within 120 days of the claim denial, or the appeal could be forfeited. A shorter deadline applies to stop recoupment on overpayment demands stemming from the denials.
After the redetermination, the second level of appeal is Reconsideration before a Qualified Independent Contractor (QIC). The QIC differs from the contractor that initially denied the claims. A provider often has the chance to submit additional documentation at both Redetermination and Reconsideration. A provider may also retain an expert to review the contractor’s assertions or submit write-ups on the individual claims.
The third level of appeal is the appearance before an Administrative Law Judge (ALJ). ALJs are employees of the Department of Health and Human Services (HHS) and may conduct a hearing on the appeal, at which witnesses and experts for the provider may testify. The contractor may appear and testify at the hearing as well, though it is not required to do so. Providers may find it difficult to submit new information to the ALJ, as they must demonstrate good cause as to why it was not submitted at the earlier levels of appeal.
The fourth level of appeal is review by the Medicare Appeals Council, which is also within HHS. The fifth and final level of appeal is review by a judge in a federal court.
Although providers are not required to retain an attorney to appeal their claims, the appeals process for Medicare claim denials can be extremely confusing and burdensome—there are also a multitude of legal and procedural arguments that can be advanced by an experienced healthcare attorney.
For over 35 years, Wachler & Associates has represented healthcare providers and suppliers nationwide in a variety of health law matters, and our attorneys can assist providers and suppliers in understanding and appealing audits and claim denials. If you or your healthcare entity has any questions pertaining to Medicare audits or healthcare compliance, please contact an experienced healthcare attorney at 248-544-0888 or wapc@wachler.com.