The Martin Law Firm is a health law firm located in Blue Bell, Pennsylvania. Attorney Jason B. Martin is an experienced healthcare attorney who represents healthcare providers facing a Medicare audit. Medicare audits are extremely challenging for healthcare providers, and it is important to have an attorney with expertise on your side to help navigate through the Medicare appeals process.
Purpose of the Medicare Appeals Purpose
The Medicare appeals process is an opportunity for the provider to challenge the CMS audit results and overpayment. If the provider can successfully overturn the denials in the Medicare appeal process, the provider will be able to retain the amounts previously paid for the disputed claims.
How the Medicare Appeals Process Works
There are five (5) levels of appeal: Redetermination, Reconsideration, Administrative Law Judge, Medicare Appeals Council and Judicial Review in Federal Court.
- Redetermination. The healthcare provider may file a redetermination appeal to the original CMS contractor within 120 days of the receipt of the initial determination letter. The contractor has 60 days to review the redetermination appeal and send the provider the results of the redetermination. The provider may present new evidence during this stage.
- Reconsideration. If the redetermination appeal is unsuccessful, the provider may request a reconsideration appeal to a QIC (Qualified Independent Contractor) within 180 calendar days of the receipt date of the unfavorable redetermination 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 QIC must issue its decision within 60 calendar days. 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.
- Administrative Law Judge (ALJ). If the reconsideration is unsuccessful, the provider may appeal the matter to an Administrative Law Judge. This appeal must be submitted within 60 days from the receipt date of the QIC’s reconsideration decision. The ALJ will schedule a hearing where the provider can provide oral testimony through video, telephone or an in-person hearing. These proceedings involve the provider, legal counsel, clinical experts and any other participants arranged by the provider.
- Medicare Appeals Council. A review by the Medicare Appeals Council may be initiated in one of three ways: by the provider following the receipt of an unfavorable ALJ decision; by CMS following the ALJ decision; or by the Medicare Appeals Council on its own motion. 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.
- Judicial Review in Federal Court. A healthcare 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.
It is critical that healthcare providers who challenge a Medicare audit determination only do so with the assistance of an experienced Medicare attorney and other experts in the healthcare field. These professionals can apply their expertise to the procedural and substantive aspects of the CMS determination and the Medicare appeals process to better prepare the case and improve chances of a successful outcome.
Contact a Healthcare Attorney at the Martin Law Firm
Successful appeals usually occur only after a diligent review of the records, consultation with attorneys and other healthcare 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.