Wiki ALJs

[yankeegirl0919]

Have any of you gone in front of an ALJ for a third level Medicare appeal? If so, any direction or advice would be extremely helpful and appreciated.

 

[lisigirl]

You can do them over the phone. I have requested one or two for my physician. In both cases, the judge only wanted to talk to the physician so I couldn't really do anything.

To set it up, we sent in our request per the instructions on the reconsideration denial. The ALJ's office will call to set up a time when your physician can get on the phone to review the case and then the ALJ's office will call back at that date and time for the hearing.

The physician usually needs to give his/her credentials before getting into the detail of the appeal. The whole thing usually takes about 10-15 minutes - at least in our case. The appeal I listened to was for a bundling denial. The surgeon explained why the procedure was necessary for the patient and he explained how the "bundled" procedure was not an integral part of the primary procedure & should be paid separately. The judge asked a few questions while reviewing the records & then agreed with our arguement. We subsequently received a separate payment.

Hope this helps.

Lisi, CPC
eharkler@nmh.org

 

[yankeegirl0919]

thank you so much! very helpful, i appreciate it.