Wednesday, February 28, 2007

Q. I heard there is a new group of administrative law judges hearing Medicare appeals. Is it still worthwhile to appeal my denied claims to an ALJ? How likely am I to succeed?
A. In 2005, the hearing process for Medicare Part B claims changed radically. Since 1989, all of these appeals had been heard by experienced judges with the Social Security Administration. However, the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) mandated that this caseload be transferred to ALJs in the Department of Health and Human Services (DHHS). The new Office of Medicare Hearings and Appeals operates with four offices handling all cases nationwide. In contrast, the Social Security judges heard Medicare cases in over 100 locations. Suppliers could usually obtain an in-person hearing within 75 miles of their location. New procedures were created by the agency to allow for videoteleconferencing of these hearings. If a telephone hearing is desired, the hearing officer will consider doing three-way calls, if arranged in advance. This enables the beneficiary to testify if he wants to be on the call.
It is also possible to request an in-person hearing, but this means traveling to one of the four regional sites. We are finding that cases are being called without significant delays. The judge's staff will supply the appellant with an exhibit list prior to the hearing, listing all of the documents in the file. Any questions about this list should be raised with the hearing assistant prior to the hearing.
The level below the ALJ--the QIC--no longer provides an opportunity to appear before a hearing officer--either in person or by telephone. The ALJ appeal level is now the first time you will get a chance to orally present your case for appeal. During the hearing, the ALJ will be interested in giving you a full opportunity to present your case.
The new ALJs seem to be fair and impartial in deciding these cases. All of these conditions mean that it is still valuable for a supplier to appeal, and the likelihood of being paid on a claim where you feel you can show "medical necessity" under Medicare program requirements is still high. hme
Valerie Eastwood is a healthcare attorney with Eastwood & Azia, PLLC. Reach her at 202-296-4100 or