Wachler & Associates Health Law BlogBasics of the Medicare Claims Appeal Process
The regulatory process for appealing Medicare claim denials and overpayments is a complex, lengthy, and administratively burdensome process. Through up to five levels of appeals, Medicare-enrolled providers and suppliers, and their representatives, must contend with inflexible deadlines, tight procedural and bureaucratic requirements, and biased reviewers, all while contesting the denials and asserting the medical necessity of the items or services at issue.
After a Medicare Administrative Contractor (MAC) has issued an Initial Demand, the letter that informs the provider of the claim denials, the reasons for the denials, and the amount of repayment demanded, the first step in appeal is Redetermination. Redetermination review is conducted by the same MAC who issued the Initial Demand and the contractor nearly always upholds its earlier decision. A provider can stop or halt recoupment of the alleged overpayment at this stage of appeal, but only if it requests Redetermination within a certain timeframe.
After Redetermination, the next level of appeal is Reconsideration. Reconsideration is conducted by a Qualified Independent Contractor (QIC), a separate Medicare contractor than the contractor that conducted Redetermination. The QIC is generally more impartial than the MAC, but often finds against the provider. A provider can stop or halt recoupment of the alleged overpayment at this stage of appeal as well, but only if it requests Reconsideration within a certain timeframe.
After Reconsideration, the next level of appeal is review by an Administrative Law Judge (ALJ). Review by an ALJ can include a hearing that resembles a miniature “trial,” with briefings, witness testimony, and evidence, or it can be conducted exclusively through paper filings, generally at the provider’s preference. Some ALJs function as independent, impartial reviewers, but all ALJs are ultimately employed by the Department of Health and Human Services (HHS). After a Reconsideration Decision is issued and during all proceeding stages of appeal, including ALJ review, the provider is unable to stop recoupment of the alleged overpayment.
After ALJ review, the next level of appeal is review by the Medicare Appeals Council (AC). The AC is the highest administrative reviewer within HHS. AC review is conducted entirely via briefings and submissions, and there is no hearing. AC decisions generally constitute final agency action and are appealable on limited grounds to federal court, the fifth level of appeal.
At each stage, there are strict timeframes and deadlines that, if missed, can forfeit the provider’s right to appeal entirely. There are also rules regarding what evidence can be presented at which levels of appeal. Legal and regulatory arguments may be presented and can have differing levels of appeal impact depending on the stage of appeal. A provider has a plethora of strategic options, decisions, and obligations regarding how to conduct an appeal of Medicare claim denials and overpayments. Experienced counsel can assist providers in navigating this process.
For over 40 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 new developments in healthcare law and regulation. 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.