Physicians Practice Pearls: Appealing Medicare Denials

CMS has established an appeals process that allows you to present your side of the story and promises a comparatively fast review of your case. It has streamlined the appeals process (from the time you submit your initial appeal to when a federal district court hands down a binding decision) from 18 months to just over one year, maximum. Understanding the process can better help you get your side of the story heard.

If you disagree with Medicare’s decision to deny payment for a given claim, first submit a written redetermination request to your Medicare carrier. There is no dollar minimum, but you must submit the request within 120 days of receiving the denial. Ask your carrier for the redetermination form.

Denied again? You can then ask for reconsideration by a qualified independent contractor (QIC). If the denial in question covers a physician service, the QIC must be a physician. You cannot choose which physician; a QIC is an independent reviewer. Get your paperwork in order, as Medicare will not grant a QIC review if you fail to supply sufficient supporting documentation. Furthermore, you will not be able to introduce additional evidence to support your case at later stages in the appeal process.

The QIC reconsideration stipulates no minimum dollar amount, but you must file your appeal within 180 days of receiving the redetermination decision. If you disagree with a denial but have no paperwork to support your case, Medicare won’t grant a QIC review.

If you find yourself denied again, you can appeal the QIC’s decision within 60 days. This means bringing your case to an administrative law judge for a hearing.

If you are again denied and you still want to pursue the matter, request a Medicare Appeals Council (MAC) review. Within 60 days, you must submit a written declaration stating why you object to the decision. The MAC, which falls under the jurisdiction of the Department of Health and Human Services Departmental Appeals Board, may agree to hear oral arguments from both parties - you and the carrier - especially if the decision hinges on a question of law, policy, or fact.

If your appeal is still denied at this point, you may request a federal district court review. You must make this final appeal within 60 days of your MAC review. The findings of the federal district court are final.

Many physicians and their staff members assume they have no recourse when Medicare denies a claim. They’re wrong: If you disagree with your carrier’s decision and submit substantial evidence to support your case, the decision can be overturned and you can collect for your services.

Elizabeth Woodcock, MBA, CPC, is a professional speaker and consultant specializing in practice management. Elizabeth is a fellow in the American College of Medical Practice Executives and a certified professional coder. She can be reached at elizabeth@elizabethwoodcock.com or via editor@physicianspractice.com. Learn more about Elizabeth at www.elizabethwoodcock.com.
This article originally appeared in the February 2007 issue of Physicians Practice.