Anatomy of the Medicare Appeals Process
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Recent changes speed up the process and make additional levels of appeal more accessible.
Fam Pract Manag. 2003 Apr;10(4):23-24.
Getting paid for what you do sometimes involves appealing claim denials. In the case of Medicare, the government has made significant structural and procedural changes in the existing appeals process. Here is an outline of those changes, so you will know what to expect the next time you appeal a Medicare denial.
The first level of appeal
Medicare carrier review, also known as redetermination, remains the first level of appeal for physician claims. However, the government has decreased the time frame in which you may request a redetermination. You used to have six months to file a request for redetermination with the carrier. Now you have 120 days. This means that you will need to be more prompt in filing an appeal if you believe it is warranted.
Medicare carriers will have less time to process redetermination requests. Previously, carriers had to process 95 percent of such requests within 45 days. Now, the law stipulates that carriers must process redeterminations within 30 days, so you should expect to receive a decision sooner.
The second level of appeal
Under the previous system, a carrier’s review or redetermination of a claim could be appealed if the amount in controversy was at least $100. The second level of appeal involved a “fair hearing” before a hearing officer at the carrier. Physicians had six months to file a request for a fair hearing, and the carrier had to handle 90 percent of such hearings within 120 days.
Under the new system, new entities called “qualified independent contractors” (QICs) will process “reconsiderations” of carriers’ initial determinations and redeterminations. Appellants will have easier access to this second level of appeal because the $100 threshold for the amount in controversy has been removed. Physicians can also expect a quicker turnaround on these second-level appeals, since QICs must process their reconsiderations within 30 days. Physicians still have essentially six months (i.e., 180 days) to file a second-level appeal.
MEDICARE APPEALS PROCESS
The third level and beyond
Under both the previous and new appeals systems, the third level of appeal is an administrative law judge (ALJ) hearing, and physicians have 60 days to file an appeal with an ALJ. The major changes in the process at this stage concern the amount in controversy that is necessary to qualify for an ALJ hearing and the time limit for ALJs to make their decisions. Under the previous system, the amount in controversy for physicians’ claims was $500, and there was no time limit on ALJs for making a decision. Under the new system, the minimum amount-in-controversy requirement is only $100, and ALJs have 90 days in which to make a decision. Thus, physicians should have an easier time getting an ALJ hearing, if needed, and they should receive a quicker decision in most cases.
The levels of appeal beyond the ALJ are the Departmental Appeals Board and Federal District Court. Appeals of physician claims rarely reach either of these levels. There have been no major changes in the process at either of these stages, except that there is now a 90-day time limit on decisions at the Departmental Appeals Board level; previously, there was no time limit on these decisions.
Medicare denials are a fact of life for most family physicians, so knowing your appeal rights is important. The changes outlined above generally benefit physicians by making subsequent levels of appeal more accessible and by facilitating more timely decisions. The flow chart outlines the new process, and two documents on the Centers for Medicare & Medicaid Services Web site provide more information: cms.hhs.gov/manuals/pm_trans/AB02111.pdf and cms.hhs.gov/providerupdate/regs/cms4004p.pdf.
Kent Moore is the AAFP’s manager for health care financing and delivery systems and is a contributing editor to FPM.
Conflicts of interest: none reported.
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