Make your case when claims are denied

Monday, December 31, 2007

Q. What is the Medicare Appeals Council, and what role does it play in the appeals process?”
A. Many providers often do not fully take advantage of the appeals process. Assigned claims that were denied by the Medicare contractor initially and upon review are then appealed to the QIC (“Qualified Independent Contractor”) and, if denied at that level, to the federal Administrative Law Judge (ALJ) level. The ALJ level is the first time the appellant has the opportunity to orally present his case, which is done by telephone, video teleconference or sometimes in person before the ALJ. If you have valid and supported claims and you make your case clearly to the ALJ, your chances of winning are good, and many providers stop at this level, whether they win or lose.  
There is another administrative level of appeal—to the Medicare Appeals Council (MAC), part of the Departmental Appeals Board (DAB) of the U.S. Department of Health & Human Services in Washington, D.C.  If the ALJ in your case has made a clear error (for example, applied the wrong coverage criteria) or failed to take into account important documentation or testimony in the record, you should consider appealing the case to the MAC. In general, you make your case with the documentation already in the file—what the ALJ saw—and you must explain why you feel the ALJ’s facts or application of the law was wrong. You must appeal to the MAC in writing within 60 days of receiving the ALJ’s decision.
If the MAC accepts your case, it is most likely that it will remand the case to the ALJ with specific directions on how to fix the problem. It is important to note that if you received a partially favorable decision from the ALJ, the MAC can review all of the ALJ’s findings—even the parts you may agree with. Also, in general, a MAC ruling is a prerequisite for taking your appeal to federal court.