Practice Management Alert

The Medicare appeals process is designed so beneficiaries and their providers who are dissatisfied with a determination on a claim can have it looked at again. According to CMS, the following are the steps in the current Medicare Part B appeals process:
 
1. Review. This is the first, formal level of appeal following denial of a Part B claim. The review is an independent, critical examination of the claim file made by carrier representatives not involved in the initial claim decision. A request for review must be made within six months of the date of initial determination on the claim. There is no dollar-amount limit on the claim.
 
2. Fair hearing. If you are dissatisfied with the determination of the review, you can request a fair hearing within six months of the review decision if the amount in controversy is $100 or more. Hearings are conducted by hearing officers assigned by the carrier. The hearing officer's role is to determine whether the carrier has followed Medicare guidelines in making the decision in question. Three types of hearings can be requested:
 

On-the-record (OTR) hearing. This hearing is based on the facts on file, including any additional documentation obtained by or furnished to the hearing officer by the claimant or the carrier.
 

Telephone hearing. This hearing, including testimony and questioning, is conducted over the telephone.
 

In-person hearing. The claimant has the opportunity to appear at a hearing in person and present testimony supporting the claim or refuting or challenging the information the carrier used to process the claim.
 
3. Administrative law judge (ALJ) hearing. If you are dissatisfied with the fair-hearing decision, you may request a hearing before an administrative law judge of the Social Security Administration within 60 days of the fair-hearing decision if the amount in controversy is $500 or more.
 
4. Appeals board. If you are dissatisfied with the outcome of the ALJ hearing, you may request a review before the appeals board of the U.S. Department of Health and Human Services within 60 days of the ALJ decision  if the amount in controversy is $500 or more.
 
5. Federal district court. If you are dissatisfied with the outcome of the appeals-board decision, you may pursue civil action in federal district court within 60 days of the board decision, if the amount in controversy is $1,000 or more.

At each level of the process, you will be notified of the decision and instructed on what steps to take, the time limits, and dollar amounts required to appeal to the next step. CMS performance standards for carriers require most reviews to be completed in 45 days, and most fair hearings to be completed in 120 days. There are no deadlines for the ALJ or appeal board to hear appeals.

Under the Benefit Improvement and Patient Protection Act of 2001, the Medicare appeals process will change for appeals of initial determinations made on or after Oct. 1, 2002. The law creates the same appeals process for both Medicare Part A and Part B claims. The new process has five steps:
 
1. Redetermination by the carrier or fiscal intermediary. Providers can request this first step in the appeals process within 120 days of the initial determination by the carrier. Redeterminations must be made in 30 days.
 
2. Reconsideration by a "qualified independent contractor" (QIC). If a provider is dissatisfied with the redetermination, a reconsideration by an independent, external contractor, known as a qualified independent contractor, must be made within 180 days of receiving the redetermination decision. QICs must issue decisions within 30 days. The secretary of the U.S. Department of Health and Human Services will contract with no fewer than 12 QICs who will use panels of physicians and other healthcare professionals in their decision-making. There is no requirement for a minimum dollar amount in controversy to bring an appeal to a QIC.
 
3. ALJ hearing. If you are unhappy with a QIC decision, and the amount in controversy is $100 or more, you may appeal to an ALJ. The ALJ will have 90 days from the date he or she receives a request for a hearing to render a decision.
 
4. Appeals board. If you are dissatisfied with the ALJ ruling, you may request a hearing by the departmental appeals board, which has 90 days from the date it receives the request for review to issue a decision.
 
5. Federal district court. If you are dissatisfied with the outcome of the appeals-board decision, you may pursue civil action in federal district court if the amount in controversy is $1,000 or more.

The law permits the HHS secretary to issue regulations that establish time limits for filing requests for hearings.
 
The law establishes a 72-hour expedited review by a QIC for cases in which a beneficiary is about to be discharged by a provider, or in which a provider plans to end services and a physician certifies that ending the services would put the beneficiary's health at significant risk.
 
Tip: A summary of changes in the Medicare appeals process, effective Oct. 1, 2002, is available on the CMS Web site at www.hcfa.gov/regs/sum-title5.htm. Scroll down to "Subtitle C Changes in Medicare Coverage and Appeals Process."