Medicare Lawyer in Pennsylvania

There are five (5) levels of appeal: Redetermination, Reconsideration, Administrative Law Judge, Medicare Appeals Council and Judicial Review in Federal Court.

1. 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.
2. 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.
3. 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.
4. 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.
5. 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.