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How to Win a Medicare Appeal

medicare appeal

If you own or operate a medical practice or other business in the healthcare industry and have questions about Medicare appeals, you are not alone. According to data from the U.S. Department of Health and Human Services (DHHS), about 10% of all Medicare fee-for-service claims are denied, and about 3% of these denied claims are appealed.

This translates to millions of Medicare appeals being filed every year. For Medicare-participating providers, filing appeals when necessary can be critical for managing their cash flow and ensuring that they are able to continue providing patient services while paying their employees. Not only can payment denials result in immediate loss of revenue, but they can also increase the risk of facing additional penalties—including prepayment review or even Medicare exclusion—in the future.

3 Keys to Winning a Medicare Appeal

Many Medicare appeals are successful. From issues within the Medicare payment system itself to flawed determinations during MAC, RAC, and UPIC audits, several issues can—and do—lead to wrongful denials. For Medicare participants, filing a successful appeal is all about taking a structured and well-informed approach—and working with experienced counsel who can help you navigate each stage of the process as necessary.

While the Medicare appeal process has several critical aspects, we can broadly identify three keys to success. These keys are:

  • Determining when a Medicare appeal is warranted;
  • Thoroughly preparing for your Medicare appeal; and,
  • Successfully navigating the Medicare appeal process.

Key #1: Determining When a Medicare Appeal is Warranted

The first step is determining when a Medicare appeal is warranted. While there are several common reasons for wrongful Medicare payment denials, there are also several common mistakes that can cause Medicare-participating providers to submit invalid claims for reimbursement.

So, when can (and should) you file a Medicare appeal? Some examples of common reasons for wrongful payment denials include:

  • Improper Application of the Relevant Medicare Billing Guidelines – Improper application of the relevant Medicare billing guidelines is among the most common reasons for wrongful payment denials. When facing audits conducted by MACs, RACs, UPICs, and other Medicare audit contractors, participating providers must proactively oversee the process to ensure that individual auditors do not apply the wrong sets of rules.
  • Application of Outdated Medicare Billing Regulations – Applying outdated Medicare billing regulations is another common reason for wrongful payment denials. The Medicare billing regulations change regularly; and, while CMS’s audit contractors should stay up to date, they often fail to do so. On the same token, applying new Medicare regulations to past billings submitted under a previous set of regulations can (and often does) lead to wrongful denials as well.
  • Incorrect Interpretation of Patient or Billing Records – Incorrectly interpreting a provider’s patient or billing records is a third common reason for wrongful Medicare payment denials. Medicare auditors routinely make assumptions in order to complete their audits as quickly as possible; and, when they do so, they almost always err on the side of assuming non-compliance.
  • Incorrect Calculation of Reimbursement Amounts Due to Flawed Auditing Methodologies – Other flaws in the audit process can (and frequently do) lead to wrongful denials as well. These include flaws in auditors’ methodologies, which often result in systematic and widespread unjustified denials of submitted Medicare reimbursements.
  • Overlooking or Ignoring Relevant Documentation – Overlooking or ignoring relevant documentation during a Medicare audit is a fifth common cause of wrongful Medicare payment denials. Here, too, auditors’ tendency to err on the side of non-compliance is a major issue that frequently leaves Medicare-participating providers forced to file an appeal.

Additionally, in some cases a denial may be justified but still subject to reversal. This could be the case, for example, if a payment is denied based on a technical violation of the applicable Medicare billing regulations but is otherwise eligible for reimbursement. Missing dates, missing signatures, and other similar types of issues can often be corrected—as long as the provider takes action in time—so that payment can be issued.

These issues, among others, can all justify—and necessitate—Medicare appeals. At Oberheiden P.C., we have extensive experience representing all types of Medicare participants during both audits and appeals, and we can use this experience to help you determine whether an appeal is warranted.

Key #2: Thoroughly Preparing Your Medicare Appeal

If a Medicare appeal is warranted, the next step is to begin your preparations. It is important to do this promptly, as strict deadlines apply.

Preparing for a Medicare appeal starts with gathering all relevant documentation. To do this, you need to know which specific payment denials are at issue, and you need to know what documentation is necessary to substantiate your practice’s or business’s claims for reimbursement. Both of these are areas where experienced legal counsel can help, and engaging counsel at the beginning of the process can help to increase your chances of success early in the Medicare appeal process.

Along with gathering all relevant documentation, it is also necessary to carefully draft the document that will initiate your practice’s or business’s appeal. This may be the Medicare Redetermination Request (CMS-20027), or it may be another document that contains all of the requisite information to formally initiate an appeal. In either case, including all required information is critical, and Medicare-participating providers must be careful to avoid including any extraneous information that could create ambiguities or unnecessary questions as well.

Taking these steps at the outset of the Medicare appeal process will help ensure that the process goes as smoothly as possible. As we discuss below, the process requires time, effort, and resources—so the more providers can do up front to help streamline the process, the better. While there are no guarantees, in our experience, this type of proactive approach to the appeal process generally affords the greatest chance of a favorable resolution early in the Medicare appeal process.

Key #3: Successfully Navigating the Medicare Appeal Process

The final key to winning a Medicare appeal is successfully navigating the appeal process. This process has five “levels.” Medicare-participating providers that need to challenge their payment denials must start at the beginning and proceed through each level as necessary until they achieve a favorable resolution.

The five levels of Medicare appeals are:

First Level of Appeal: Redetermination By a Medicare Contractor

Providers must initiate the Medicare appeal process by filing a request for redetermination with a Medicare Administrative Contractor (MAC). As CMS explains, “[a] redetermination is a review of the claim by [MAC] personnel not involved in the initial claim determination.” To request a redetermination, a provider must file form CMS-20027 (or another compliant request) within 120 days of receipt of the relevant notice of denial.

Second Level of Appeal: Reconsideration By a Qualified Independent Contractor (QIC)

The second level of appeal is reconsideration by a Qualified Independent Contractor (QIC). A request for reconsideration must be filed within 180 days of receipt of notice of a denial of a redetermination request. Requesting reconsideration involves filing form CMS-20033 (or another compliant request) which includes an explanation of the justification for the request as well as identification of any relevant documents not referenced in the notice of denial.

Third Level of Appeal: Decision By the Office of Medicare Hearings and Appeals (OMHA)

If the QIC agrees with the MAC and upholds denial of payment, the next step is to request a review by the Office of Medicare Hearings and Appeals (OMHA). The OMHA is an independent office within CMS that is tasked with conducting unbiased reviews of Medicare payment denials that have been affirmed during the first two levels of the Medicare appeal process.

OMHA appeals can proceed in one of two ways: If desired, the provider can request a hearing before an administrative law judge (ALJ). These hearings typically take place via phone or video conference. If a hearing isn’t desired, a provider can opt instead to have the record reviewed by an attorney adjudicator.

Fourth Level of Appeal: Review By the Medicare Appeals Council

If a provider disagrees with the outcome at the OMHA, the fourth level of the Medicare appeal process is review by the Medicare Appeals Council. Here, too, providers have the option to request a hearing, which provides an opportunity for their counsel to present their arguments orally to the members of the Council.

Fifth Level of Appeal: Judicial Review in Federal District Court

Finally, if a Medicare-participating provider exhausts its administrative remedies and is not satisfied with the outcome, the provider can appeal its payment denial(s) in federal district court. This is a different process entirely, and winning a Medicare appeal in court requires highly experienced counsel who are intimately familiar with the claims at issue as well as what happened at the lower levels of the Medicare appeal process.

Speak with a Senior Medicare Appeals Lawyer at Oberheiden P.C.

Do you need to know more about the Medicare appeal process and what it takes to reverse a wrongful Medicare reimbursement denial? If so, we encourage you to contact us promptly. To speak with a senior Medicare appeals lawyer at Oberheiden P.C. in confidence as soon as possible, please call 888-680-1745 or request an appointment online today.

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