Practice Management Alert

Take contractor's priorities to heart to win appeals

The double standard for Medicare contractors versus Medicare providers is evident once again in appeals priorities issued by CMS.
 
"If providers are even a day late, they are out of the ballpark," says Burtonsville, Md.-based attorney Elizabeth Hogue. "But there is so much leeway for contractors that [appeals] timelines almost seem meaningless."
 
This leeway is made clear in Aug. 22 program memorandum AB-03-133, in which CMS sets out the priorities carriers should use when "the budget amount is insufficient to adequately perform the required functions" for appeals, CMS states.
 
CMS states that contractors should generally adopt a first-come, first-served take to appeals processing, but says budget constraints sometimes make it necessary for contractors to "prioritize the processing of appeals to more efficiently manage the workload." Topping contractors' appeals priority lists are implementing decisions from a variety of bodies ranging from administrative law judges and the Departmental Appeals Board down to medical review.
 
The remainder of the appeals priority hierarchy is as follows, from most to least priority:
  requests for telephone appeals
  written reconsiderations, reviews and hearing-officer hearings from beneficiaries or their representatives
  written reconsiderations, reviews and hearing- officer hearings from providers, suppliers and others that are submitted with all necessary documentation
  written reconsiderations, reviews and hearing- officer hearings from providers, suppliers and others that are submitted without all necessary documentation. Once all those appeals are taken care of, carriers are to "prepare, assemble and forward" administrative law-judge-hearing case files that contain all necessary documentation, and then turn their attention to those that don't. Last on the list of priorities is submitting agency referrals to the Departmental Appeals Board.
 
Editor's note: The program memo is at www.cms.gov/manuals/pm_trans/AB03133.pdf.