Five things every provider should know about appeals

Wednesday, September 30, 2009

Ft. LAUDERDALE, Fla. - Healthcare attorney Lester Perling has been doing a lot of writing these days on the Medicare appeals process.

Last year, Perling, a partner in the law firm of Broad and Cassel, penned the Medicare Claims Appeals Process Handbook, and most recently, he contributed a chapter ("Overview of the Medicare Parts A&B Claims Appeals Process") to the 2009 Medicare and Medicaid Reimbursement Update. Both books are intended to help HMEs and other providers navigate the Medicare bureaucracy.

Here's Perling's Top 5 list of what providers should be aware of when it comes to appeals.

* Deadlines: Respect all deadlines associated with the appeals process. In a worst case scenario, if you don't file your appeal in time, it will be thrown out. That means you can kiss your money goodbye.

* A special case: You have 120 days to file your initial appeal, but you must file it within 30 days to avoid recoupment. If you lose this initial appeal (a redetermination), you have 180 days to file a reconsideration. You must file for the reconsideration within 60 days of the redetermination to avoid recoupment. If you miss these deadlines, you'll get your money back if you win, but the recoupment could cause serious cash-flow problems.

* Documentation: The rules require that all documentary evidence be submitted at the reconsideration stage. Additional information cannot be submitted afterward unless for a very good cause.

* Hold CMS accountable: Medicare contractors must open an appeal within a specific period of time or they can't recoup. Likewise, your liability could be waived if you acted on incorrect information provided by CMS.

* Remember: The recovery audit contractor appeal processs is the same as the standard claim appeals process. A lot of providers believe the processes are different, but that is not the case. The same deadlines apply. HME