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Medicare Compliance & Reimbursement

PHYSICIANS:

New Appeals Rules Alter Almost Everything

Published on Sun Jan 01, 2006

Physicians must get up to speed before January rolls around.

Starting Jan. 1, physicians will have a new appeals process to cope with, according to a recent Medlearn Matters article (MM4019).
 
The basics: Carriers will still perform the first level of appeals--which will now be known as a redetermination--and physicians will have 120 days to request this level of appeal. Physicians will have 180 days to file a request for the next level of appeal, known as a reconsideration, which will be performed by the Qualified Independent Contractor. After that, doctors have 60 days to request the third level of appeals, the Administrative Law Judge.

In January, the minimum amount at stake for an ALJ appeal will go up from $100 to $110. If the ALJ doesn't work for the appealing doctor, she has 60 days to appeal to the Department Appeals Board. And after that, she has 60 days to appeal in federal court, as long as there is at least $1,050 at stake.

Minor errors: CMS says that a minor error on a claim that triggered a denial may not require an appeal. Instead, the physician can ask the carrier to reopen the claim so the medical office can correct the problem, instead of going through the appeal process.
 
Late filing: Carriers can still accept requests for redetermination after the 120-day deadline. The carrier has until Jan. 1 to come up with a procedure for deciding if the physician had a good reason to submit the request late, according to CMS.

A request for redetermination is received on the date that the carrier's corporate mailroom receives the document, according to Medlearn Matters article 3942.

Heads up: Some experts are concerned that physicians may miss the deadline for requesting a reconsideration because they have 180 days, not six months, according to Tammy Tipton, president of Appeal Solutions in Blanchard, OK. Remember: The 180 day-window also includes weekends.

The most important change to the appeals process is the fact that a physician must submit a complete case, including all documentation, to the carrier at the first level. After that, the physician can only add more information for "good cause" or to correct clerical errors, says Deborah Churchill, president of Churchill Consulting in Killingworth, CT.

Also under the new process, the carriers won't be able to collect any overpayments from a physician until they complete the appeals process--and only if they win.

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