ALJ Appeals: Increase your success rate

Q. What can suppliers do to increase their chances of success during the Medicare appeals process?
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Friday, October 21, 2016

A. If you find yourself in the unfortunate position of having to submit a Medicare request for redetermination or reconsideration, make sure that you are thoughtful in your submission and that you pay attention to the details provided in the overpayment demand. 

Redetermination 

Redetermination requests must comply with regulatory deadlines—the request must be submitted within 120 days of receipt of the initial determination or filed within 30 days to stay recoupment, and the Medicare Administrative Contractor has 60 days to issue a redetermination decision. The MACs are required to make decisions based on Local Coverage Determinations and Medicare manuals. On redetermination requests, a supplier should use both of these authoritative sources to show why the claims should have been paid.

Reconsideration 

If the redetermination decision is unfavorable or partially unfavorable, the supplier may file a request for reconsideration. Reconsideration requests must also comply with regulatory deadlines—the request must be filed within 180 days of receipt of the redetermination decision and the Qualified Independent Contractor has 60 days to issue its decision. But, if a supplier wishes to continue to stay recoupment, the supplier must file the reconsideration request within 30 days of the reconsideration decision. QICs are bound by National Coverage Determinations and CMS rulings. A supplier should focus its arguments on Administrative Law Judge and Departmental Appeal Board decisions, using precedent to strengthen its interpretation of the NCDs.

R. Ross Burris, III and Matthew Agnew, who contributed to this article, are attorneys at Polsinelli PC. Reach them at rburris@polsinelli.com or magnew@polsinelli.com.

Comments

Two important tips:

  • Make sure you understand exactly what the issue is. It could be the quantity (monthly limit, too soon after previous order, etc.), the diagnosis, or whatever, but if you misunderstand what caused the denial, you probably won't be able to fix the problem.
  • Double and triple check the documentation you send with your appeal. Is everything signed and dated? Are the signatures and dates legible? Is the documentation from the correct time period?