The nuts and bolts of Medicare appeals

October 1, 2007

When you plan to appeal an audit, it's important to know that there's a new process in place. Here are the details.

Editor's Note: The following article presents an overview of the issues inherent in appealing a Medicare audit. The examples in this article should not be interpreted as legal or reimbursement benchmarks. For definitive answers to questions about Medicare appeals, consult an attorney or a recognized authority on the subject.

Royal Oak, MI-Appealing a Medicare audit requires extensive knowledge of the process, according to Andrew B. Wachler, Esq., who practices health-care law at Wachler & Associates PC, Royal Oak, MI.

"Post-payment audits are quite defensible, and the appeals process is one that can work," said Wachler, adding that his firm deals primarily with post-payment audits-when the government comes in after the fact, reviews the charts, statistically samples and rejects, and takes money back.

First-level appeals

The first step in the new appeals process is for providers to have initial determinations: pay or not pay.

"We need to look at their records to find the reasons for denial," he said. The next step of an appeal, according to Wachler, is a "redetermination," which used to be called an informal review.

"We found that many carriers give providers an opportunity for rebuttal, a process where a claim is denied before you formally get to an initial determination. The rebuttal probably comes before an initial determination, because the clock starts ticking on these processes and not every carrier provides a rebuttal," Wachler said.

If you are working on a prepayment basis-a claim that's not paid on a case-by-case state-you may make it to the administrative law judge (ALJ) stage, which may handle the case as a redetermination.

There are specific timeframes in which to appeal, Wachler said.

"If you miss the timeframes, you're out," he cautioned. Deadlines for appeals are 180 days for a request for reconsideration for a qualified independent contractor (QIC), 120 days to file a request for redetermination, 60 days for an ALJ, and 60 days for Medicare appeals council.

"In the past, you could get away with making a mistake if you made a phone call. Today, it must be in writing," Wachler said.

The appeals process differs, depending on whether you're a Medicare Part A or Part B provider.

According to Wachler, a Part A provider never will receive a reconsideration; the case would head directly to a demonstrative law judge. Part B providers, including physicians, go from the carrier hearing before a Part B officer to an ALJ.

Second-level appeals

The second level of appeals previously was the Part B hearing. A provider took a claim to a hearing officer and explained why he or she was entitled to payment. "From a prepayment perspective and on a claim-by-claim basis, there was a face to talk to," Wachler said.

Now that process has been replaced with the QIC stage, which involves a panel of health-care experts. Providers are back to a paper review of records instead of an in-person hearing. Initial determination would be whatever the provider wants to submit to the QIC.

"From a post-payment setting, as an advocate in this process where you previously dealt with a hearing officer, you worked with a carrier representative, but you went there with your physician-your authority-to support your positions. Surprisingly, we won most cases at this stage," he said.

Wachler noted that the QIC is bound by national-not local-coverage decisions.

"What that means is, if you don't fall within a local medical review policy, that doesn't mean you lose," he said.