# Third Level Appeal (ALJ)



## beev (Nov 4, 2008)

Any tips for this hearing?  I just mailed my request for ALJ yesterday.  I rec'd an "unfavorable" decision from QIC who in my opinion didn't even read what I was appealing.  We had incorrectly billed a bilateral hip replacement done in the same operating session by two different physicians.  Prior to billing this I contacted Medicare and was told to bill the same way they recommend billing bilateral knees in same session by two physicians using modifiers 50 and 62.  I have documentation of conversations with 2 different people from WPS telling me this was correct.  Come to find out it shouldn't have been billed that way after I spoke with someone teaching a WPS Medicare Seminar, therefore, had to start to "appeal process"   I am so frustrated over this and cannot understand why QIC delivered an unfavorable decision stating it didn't support co-surgeons even though I clearly explained the situation to them!


----------



## fredabrinson (Nov 4, 2008)

*Appeals*

Hello Beev,

It's been a long time since I was directly invovled with appeals but I was successful back in the day!  One of the big changes I made in our process was requesting a telephone hearing at that second appeal level, instead of sending in the documentation again with an explanation letter.  Talking directly with the hearing officer was a big benefit, and I was luck enough to get the same officer almost every time!  We developed a very good working relationship and was able to share learned information that helped both of us.  (He understood where I was coming from, and I understood some of the "why" a little better).  I did request and participate in an A L J hearing.  I believe this was by telephone also but I can't remember for sure as it has been a long time ago.  It was tougher than the hearings I was familiar with, and I think at least one outcome was positive, but I cannot remember this for sure.

Sorry I can't be more helpful.  I do recommend moving ahead if you believe in your documentation.

Good luck!


----------

