Practice Management Alert

When your Medicare Part B carrier conducts a review of your appealed claim and upholds its original decision, should you take the next step in the Medicare appeals process? If you feel your appeal is justified, have the documentation to support your argument, and meet the Medicare requirements to move to the second, fair hearing step, billers and practice managers say you should absolutely continue. Many practices find that when they receive an unfavorable decision at the review step, appealing to the fair hearing step produces favorable results.
 
The key to winning at the fair hearing is having the documentation to support your claim and your argument. "Having the documentation from the physician is number one," stresses Joshua Klinge, CPC, HRS, chief executive officer of Optimum Reimbursement Services Inc., a medical billing company based in Huntington Beach, Calif., that specializes in appeals for surgeons. "If the documentation is not there to substantiate what you are billing and arguing, the hearing officer will not even consider siding with you."
 
A hearing officer appointed by the Medicare carrier conducts the nonadversarial, fair hearing. Although the hearing officer can be an employee of the carrier, based on a 1982 U.S. Supreme Court ruling, CMS in its Medicare Carriers Manual mandates that the officer must be independent. CMS requires a hearing officer to have a thorough knowledge of the Medicare program, including the laws and regulations that it is based on, and CMS rulings and policies. The hearing officer must not be involved in any way in the initial determination or appeal to the review step with the claim at issue. Officers can be attorneys or individuals who can conduct formal hearings and have a general understanding of medical issues and terminology.
Requirements for Fair Hearing
To qualify for the fair hearing, your claim must have been appealed through the review step and have at least $100 in controversy. (See page 3 to learn how to determine the amount in controversy.) You have six months from the date of the review determination to file a request for the hearing. The request for a hearing must be made in writing, by sending a letter to the Medicare carrier or by completing Form CMS-1965, Request for Hearing, Part B Medicare Claim, which you can obtain from your Medicare carrier. If you choose to request a fair hearing by letter, as most practices do, it should include the following:

  a statement of dissatisfaction with the review determination
  a request for a hearing before a hearing officer and the type of hearing desired
  the name of the patient
  the health-insurance claim number
  the carrier's name and address
  your name, address, phone number and signature
  why you disagree with [...]