Scope of Review of Medicare Council Reviewing Alj Dismissal

(August 15, 2012):  Is this your first time being audited by a Medicare Administrative Contractor (MAC) or a Zone Programme Integrity Contractor (ZPIC)?  If and then, the brief outline below can provide a handy summary of the Medicare appeals process.

I.  Stride 1 - Asking for Information:

In most instances, a wellness care provider will receive notice of a Medicare post-payment audit by mail, either from the provider's MAC or the ZPIC responsible for treatment that region. This initial correspondence is pregnant. From this letter, a provider tin can usually surmise whether the initial review is merely a probe audit or an allegedly statistically relevant review.  Perhaps almost importantly, a provider tin can typically learn the scope of the contractor's review.  While many requests for documentation are express to medical records and claims-related documentation, nosotros are now seeing an increase in the number of audits where the ZPIC or MAC has also requested copies of "business organisation" records, such as a list of current and past employees, copies of contracts, and other materials which can assist the regime in determining whether a provider is currently (or has) engaged in conduct which might violate the federal Anti-Kickback Statute or the Stark law.

While many providers feel comfortable responding to a MAC or ZPIC's request for information, they do not always realize that pre-emptive steps tin be taken at this indicate to help them present their documentation in its best light.  Every bit important, a provider may non fully appreciate the importance of maintaining an accurate record for the Medicare appeals process.  Efforts to improperly supplement or correct an incomplete medical record can betrayal a provider to criminal liability. Providers must understand the rules. Don't inadvertently turn a mere overpayment thing into a criminal case.

II.  ane^st Level of Appeal – Re-determination:

After assessing the documentation submitted, a MAC or ZPIC volition so notify a provider in writing of their results.  Please note, if the initial Medicare audit was conducted by a ZPIC, you volition start receive the ZPIC's results – a need letter from your MAC will likely arrive within a few days.  The Medicare audit decision letter of the alphabet and its attachments volition identify any claims institute to qualify for coverage and payment and should hash out why any denied claims did non Medicare's payment requirements.

The MAC's need letter serves as a "revised initial determination."  Unfortunately, a large part of the Medicare post-payment audits conducted by ZPICs find that the bulk of claims should not take been paid.  Upon receipt of the MAC's demand letter of the alphabet, y'all take 120 days to file an appeal with your MAC for re-determination . Yet, to avoid recoupment, you should file this appeal inside thirty days of the date written on the MAC's letter.  Rather than risk having monies recouped, the all-time practice is just to ensure that your appeal is received within 30 days of the date of the need letter.  The first level of the Medicare administrative appeals process involves a contractor from the Centers for Medicare & Medicaid Services (CMS) , highlighted on the HHS organizational chart in yellow.

III.  2^nd Level of Appeal – Reconsideration:

Afterwards receiving a re-conclusion decision from the MAC (which, like the ZPIC's finding, is usually unfavorable), y'all have 180 days to file a request for reconsideration with the Qualified Independent Contractor (QIC) assigned to your area. During this process, the QIC will review the documents you've submitted and make an independent conclusion about the propriety of coverage and payment for the claims at issue. To avert recoupment at this level, y'all need to file an entreatment inside 60 days of the date of the re-decision determination.  Once more, the best practice is to base your filing deadline on the engagement of the QIC's decision letter of the alphabet. This level of the Medical administrative appeals process  also involves a CMS contractor, once more highlighted on the HHS org chart.

IV. iii^rd Level of Appeal – Administrative Law Gauge Hearing:

While the QIC sometimes issues favorable decisions, it oftentimes agrees with the contractors below and upholds the denial of your Medicare claims. At this bespeak, you should file an appeal with an Administrative Constabulary Estimate (ALJ). This must be washed within lx days from the date of receipt of the QIC'due south afterthought decision alphabetic character. Keep in mind, in social club to qualify to file the ALJ appeal, you must meet all other statutory requirements (such as an amount in controversy over $130). Notably, it has been our experience that the ALJ level of the Medicare appeals process has been the well-nigh reasonable and provider-friendly, although each ALJ is different. This level of appeal goes through the Role of Medicare Hearings and Appeals (OMHA), which is highlighted on HHS' org chart.

V.   4^th Level of Appeal – Medicare Appeals Quango

If the ALJ decision is unfavorable and you choose to appeal (or in some cases, the decision is provider-favorable and the Administrative QIC (the AdQIC) asks for a review), the side by side level of the Medicare appeals process is the Medicare Appeals Council (the Council) . The Quango is fabricated up of senior ALJs with significant skill and experience in Medicare administrative matters. The Council by and large looks at errors of law and abuses of discretion, similar to an appellate court. There are too a number of statutory bars that an appellant must overcome to take the Council review its case. The Council is office of the Departmental Appeals Board (DAB), which is highlighted on the HHS nautical chart here.

VI. v^th Level of Appeal – Federal District Courtroom

If a provider has non still obtained the relief they seek at the lower levels of appeal, they may appeal the unfavorable Medicare claims decision to a Federal District Court (usually the district the provider'due south office is in, although it is possible that a provider may besides appeal to the Federal District Court for the Commune of Columbia, since the Secretary of HHS is located hither). Importantly, the Commune Court looks at Medicare appeals cases with a high degree of deference to the Bureau'southward determination. That is, the District Court Approximate will ofttimes side with CMS and HHS unless the lower ALJ'south determination was "capricious and capricious" or "confronting the substantial weight of the prove." In the legal world, these are incredibly difficult standards to overcome, and providers generally practise not have a great bargain of success in court, especially considering the costs of the litigation. Nonetheless, it is an option that exists for dissatisfied providers. Since the Commune Court is non a part of HHS, it is non included in HHS' organizational chart.

VII.  Final Remarks:

Every bit you tin can imagine, the Medicare appeals procedure is ultimately much more complicated than this brief outline may suggest.  Representatives of the auditing ZPIC, the MAC and / or the QIC may cull to participate in the ALJ hearing in order to present their arguments in back up of denial. Although these proceedings are technically "not-adversarial," these hearings can be both stressful and complicated, especially when both sides support their arguments with statistical and clinical experts. In any upshot, ALJs are experts at cutting through the smoke and determining whether claims do, in fact, qualify for coverage and payment.

While we recommend that providers avail themselves of the Medicare post-payment appeals process, information technology is essential that prior to filing an appeal, providers critically examine their claims and associated documentation.  Like information technology or not, sometimes the Medicare contractors are correct – some claims shouldn't be paid.   At the stop of the day, providers need to conduct an honest assessment.  Does a particular claim truly authorize for coverage and payment?  If not, its mail-payment denial should not exist appealed.  Every bit we e'er say, " if it'southward non yours, requite it dorsum. " That is, if y'all can't make a good religion statement nigh why certain claims are payable, they probably aren't. Similarly, unrelated to the appeals process, have you lot identified claims that were erroneously paid?  It is ofttimes a good idea to consult with qualified health constabulary counsel before reporting and returning an overpayment or going through the Medicare appeals process.

Robert Lilesrepresents providers in Medicare post-payment audits and appeals, and similar appeals nether Medicaid. In add-on, Robert counsels clients on regulatory compliance problems, performs gap analyses and internal reviews, and trains healthcare professionals on various legal issues. For a costless consultation, phone call Robert today at 1 (800) 475-1906.

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Source: https://www.lilesparker.com/2012/08/16/medicare-administrative-appeals-process/

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