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Medicare Audits & Medicare Appeals - Healthcare Provider Appeals

In order to effectively evaluate and consider the merits of each Medicare appeals case, it is critical that providers and legal counsel have an in-depth understanding of applicable CMS Payment Criteria - medical necessity issues, claim submission guidelines, site or setting limitations, coding variables, billing parameters and required clinical documentation elements.

Jackson Davis HealthCare leads the nation in understanding, documenting and applying CMS Payment Criteria for cases being considered for Medicare audits and Medicare appeals - RAC appeals, ZPIC appeals, PSC appeals, MAC appeals, MIC appeals or individual Medicare beneficiary appeals.

Recommended Medicare Appeals Process

Medicare appeals are won or lost with clinical documentation that clearly, concisely and unambiguously incorporates required CMS Payment Criteria.  Whether the focus area is short stays for cardiac-related diagnoses, Inpatient Rehabilitation Facility (IRF) admissions, PCI / Implantable Cardioverter Defibrillators (ICDs), Emergency Room visits with modifier 25, excisional debridement documentation, HME supply issues or any other focus area - CMS Payment Criteria is the single best foundation for winning appeals.

The following is an overview of the Jackson Davis HealthCare recommended Medicare appeals approach:

1)  Step 1 - Perform CMS Criteria-Based Case Review

Jackson Davis HealthCare physicians, nurses, billing compliance professionals and legal services staff will evaluate each denial / overpayment determination case and compare the available clinical documentation to required CMS Payment Criteria.  CMS criteria-based case reviews include a detailed the evaluation of underlying clinical considerations, supporting medical records documentation, CMS Payment Criteria comparative analysis and estimated financial impact.

2)  Step 2 - Prepare Medicare Appeals & CMS Criteria-Based Case Summary

Based upon the outcome of the CMS criteria-based case review, we prepare all medical records, required CMS supporting documentation and a CMS appeals criteria-based case summary to accompany the submission to the Medicare Administrative Contractor (MAC).

3)  Step 3 - Submit Medicare Appeals & Required Documentation for Redetermination

Submit all required CMS documentation to the Medicare Administrative Contractor and coordinate with provider staff and selected legal counsel throughout the Redetermination & Reconsideration process (CMS appeals - stages 1 & 2).  Medicare appeal will be filed within 30 days of denial in order to stop the recoupment process.

4)  Step 4 - Submit Medicare Appeals & Required Documentation for Reconsideration
 
If the provider's appeal efforts are not initially successful in the Redetermination stage, Jackson Davis HealthCare professionals will work collaboratively with internal legal counsel or select health law firms to most effectively and aggressively challenge Medicare audits recoupment throughout the remaining steps of the Medicare appeals process.  Medicare appeals will be filed within 60 days of redetermination to stop the recoupment process.

5)  Step 5 - Submit Medicare Appeals & Provide CMS Regulatory and Clinical Expert Testimony at ALJ Hearing

If the provider's appeal efforts are not initially successful during the initial 2 stages, Jackson Davis HealthCare can provide a full range of expert regulatory & clinical testimony in support of a provider's adherence to CMS Payment Criteria at ALJ hearings and or subsequent judicial proceedings.

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Turning the Page - The Ultimate (Winning) Medicare Appeals Strategy

With the Medicare & Medicaid audit program being in full force nationwide, providers are preparing for CMS audit denials and setting in motion a series of processes to successfully address CMS appeals.  Hospitals, physicians, physical therapists, DME suppliers and a full range of other healthcare providers are quickly and aggressively turning their focus to fighting & winning CMS appeals.  Defending Medicare or Medicaid auditor denials, avoiding potential CMS fraud allegations and holding on to hard earned cash reserves are all critical.

Based upon our work with providers facing CMS audits (PSC audits, ZPIC audits, RAC audits and MIC audits), the 4 most frequently asked questions are (1) how do we keep our money, (2) how do we stop CMS audits and denials in the future, (2) how do we win current CMS appeals, and (3) how do we stop CMS audit outcomes from turning into 'fraud' allegations.

Within the Medicare Appeals section we address a wide range of issues and strategies to consider when initiating the Medicare appeals process.  Most importantly, however, we simply can't emphasize enough the challenges to winning CMS appeals and the very real possibility of CMS audit outcomes becoming potential Medicare fraud issues.  Here are a handful of things to consider when tackling CMS appeals:

1)  CMS Payment Criteria will give you the winning hand

Several U.S. courts have held that a provider's adherence to CMS Payment Criteria trumps all in the evaluation of claim denials.  In fact, the courts have held that - when CMS payment criteria exists for a given focus area - CMS MUST use the payment criteria when evaluating claims for payment.

2)  Develop CMS Criteria-Based Case Summaries for all "winnable" CMS appeals

Nothing speaks louder in the Medicare or Medicaid appeals process than providers that painstakingly tie CMS Payment Criteria to medical records documentation and present an evidence-based argument for payment.  On the other hand, using the "appeal everything" strategy and not making internal operational changes to adhere to CMS payment criteria is a guaranteed approach to facilitating potential Medicare or Medicaid fraud investigations.

3)  Submit all required documentation during the first 2 stages of the appeals process
 
It is critical that you file all the supporting documentation relating to a given case no later than Stage II - Reconsideration.  After this stage, it is extremely difficult to add supporting documentation to a case under appeal.  When completing CMS appeals and "mock audits" with providers across-the-country, we have found a number of hybrid medical record structures and significant challenges to submitting medical record documentation for review.

4)  Focus on adhering to CMS Payment Criteria and winning your appeals

Remember, the Medicare Appeals Council is the last administrative step in the Medicare appeals process.  The Appeals Council relies heavily on CMS payment criteria in making decisions and their approach has shown time-and-time again that "legal or procedural" arguments are extremely difficult to win.
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CMS / Medicare Appeals Resources

The Medicare appeals can be challenging and may expose the provider to a wide range of Medicare fraud related issues.  Please see the Medicare Appeals section for further information and guidance relating to recommended appeals work plan components.  The following are CMS PSC appeals documents highlighted on the cms.hhs.gov website:

                        Medicare Appeals - The Medicare Appeals Brochure
                        Medicare Appeals - Appeals Process Diagram
                        Medicare Appeals - Limitation on Recoupment
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Medicare Appeals - Denials & Overpayment Determination

The following information MUST be included with your request for all appeal levels:

Beneficiary name
Medicare Health Insurance Claim (HIC) Number
Specific service(s) and/or item(s) for which the redetermination / reconsideration is being requested
Specific date(s) of the service; and
Name and signature of the provider or the representative of the provider

First Level – Redetermination (Medicare Administrative Contractor)

Claim denials or overpayments must be initially reviewed (appealed) to the appropriate Medicare Administrative Contractor (MAC) by requesting a redetermination of the claim within 120 days of the Medicare's initial decision.  Medicare Administrative Contractors are required to respond to a provider’s request for redetermination within 60 days of receipt.

Second Level – Reconsideration (Qualified Independent Contractor)

If a provider is dissatisfied with the outcome of the Level 1 appeal or redetermination process, a request for “reconsideration” may be filed with the appropriate Qualified Independent Contractor (QIC) within 180 days of the redetermination.  Requests for reconsideration are required to be processed within 60 days by the QIC.

Third Level – Administrative Law Judge Hearing

If a provider is not satisfied with Level 2 and the result of reconsideration, a hearing before an Administrative Law Judge (ALJ) can be requested.  The amount in controversy must be a minimum of $120 and requests for a hearing from an ALJ must be received within 60 days of the provider’s notice of the reconsideration outcome.

Fourth Level – Medicare Appeals Council (MAC)

If the Level 3 appeal and decision by the ALJ is considered unfavorable by the provider, a fourth level appeal request may be filed with the Departmental Appeals Board (DAB) / Medicare Appeals Council (MAC).  Requests for a MAC review must be filed within 60 days of receipt of the ALJ’s decision.  The MAC must subsequently issue a determination within 90 days of the review.

Fifth Level – U.S. District Court Review

If the Level 4 decision of the MAC is deemed unfavorable to the provider, the final step in the appeals process is to file suit in U.S. District Court.  Requests must be filed within 60 days of the MACs decision and the amount in controversy must be at least $1,180.

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CMS Transmittal 141 - Limitation on the Recoupment of Medicare Audit Overpayment Determinations

CMS Transmittal 141 specifically addresses a diverse range of Medicare appeals issues and discusses revisions to the Medicare appeals process.   Probably the most important aspect of Transmittal 141 is the timing of recoupment by CMS for overpayment determinations by contracted recovery auditors.