Audits: File quickly on appeals

Q. Is it worth appealing a denial from the RAC or ZPIC auditor?
Tuesday, September 24, 2013

A. With the increased audit activity over the past year, appealing overpayment determinations is necessary to avoid recoupment and keep your head above water. 

Know the timelines

After you receive an overpayment notification, the timeline for filing a redetermination request is 120 days. To avoid recoupment, you must file your appeal within 30 days. Lately, the Medicare Administrative Contractors (MACs) appeal departments have been slow to process appeals and signal the financial department to stop the recoupment process. Medicare has started recovering overpayments despite suppliers filing an appeal on the 28th or 29th day. File your redetermination early to allow the MAC time to process the appeal and stop the recoupment.  

After redetermination, the next level of appeal is the reconsideration. Generally, you have 180 days to file for reconsideration. In the case of an overpayment, you must file your reconsideration request within 60 days to stop recoupment. Again, file early to allow the contractor time to notify the finance department of your appeal. The third and fourth levels of appeal are to the Administrative Law Judge (ALJ) and the Medicare Appeals Council, respectively. Unfortunately, after reconsideration, Medicare will begin recoupment. At this point, establish a repayment plan with Medicare as you file your appeals with the ALJ and Appeals Council.  

Submit a complete appeal

The best practice is to submit complete documentation at the audit stage. If you cannot gather everything in time for your audit response, file your response and continue to collect any missing documentation or attestations needed to make a complete file for your appeal.

Jillian Longo is a consultant with Harrington Management Group, LLC. Reach her at or 888-833-3478.