Posts Tagged Medicare

CMS Reveals New Medicare Card Design; Strengthens Fraud Protections

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CMS Reveals New Medicare Card Design; Strengthens Fraud Protections

The Centers for Medicare & Medicaid Services has redesigned its Medicare card to remove Social Security numbers and use a unique, randomly-assigned number in an effort to better protect users from identity theft and fraud.

CMS will begin mailing the new cards to people with Medicare benefits in April 2018 to meet the statutory deadline for replacing all existing Medicare cards by April 2019. People with Medicare will also be able to see the design of the new Medicare card in the 2018 Medicare & You Handbook. The handbooks are being mailed and will arrive throughout September.

“The goal of the initiative to remove Social Security numbers from Medicare cards is to help prevent fraud, combat identify theft, and safeguard taxpayer dollars,” said CMS Administrator Seema Verma. “We’re very excited to share the new design.”

CMS has assigned all people with Medicare benefits a new, unique Medicare number, which contains a combination of numbers and uppercase letters. People with Medicare will receive a new Medicare card in the mail, and will be instructed to safely and securely destroy their current Medicare card and keep their new Medicare number confidential. Issuance of the new number will not change benefits that people with Medicare receive.

Health care providers and people with Medicare will be able to use secure look-up tools that will allow quick access to the new Medicare numbers when needed. There will also be a 21-month transition period where doctors, health care providers, and suppliers will be able to use either their current SSN-based Medicare Number or their new, unique Medicare number, to ease the transition.

This initiative takes important steps towards protecting the identities of people with Medicare. CMS is also working with healthcare providers to answer their questions and ensure that they have the information they need to make a successful transition to the new Medicare number. For more information, please visit: www.cms.gov/newcard.

How can providers get ready for the changes?

  • Ask your billing and office staff if your system can accept the new 11-digit alphanumeric Medicare Beneficiary Identifier or
  • If your system cannot accept the new number, system changes should be made by April 2018
  • If providers use vendors to bill Medicare, ask them about their MBI practice management system changes and make sure they are ready for the change
  • Verify your patients’ addresses: If the address you have on file is different than the address you get in electronic eligibility transaction responses, ask your patients to contact Social Security and update their Medicare records. This may require coordination between your billing and office staff.

For more information go to https://www.cms.gov/Medicare/New-Medicare-Card/Providers/Providers.html

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Fewer Physicians Could Be Audited under a New CMS Program

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Fewer Physicians Could Be Audited under a New CMS Program

Fewer physicians will undergo audits under a new Medicare claims review process, according to a Centers for Medicare & Medicaid Services announcement.

CMS will roll out a new approach to claims review nationwide targeting fewer providers and requiring review of fewer claims. The new policy, to take effect later this year, makes it less likely doctors who have sound billing practices will face a Medicare audit.

Under the Targeted Probe and Educate (TPE) program, Medicare Administrative Contractors will focus “only on providers/suppliers who have the highest claim error rates or billing practices that vary significantly out from their peers,” according to the CMS announcement. Providers/suppliers with continued high error rates after three rounds of TPE may be referred to CMS for additional action, which may include 100 percent prepay review, extrapolation, referral to a Recovery Auditor, or other action. Providers/supplier may be removed from the review process after any of the three rounds of probe review, if they demonstrate low error rates or sufficient improvement in error rates, as determined by CMS.

Read the full CMS announcement here

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Physicians Maintain High Standards

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Physicians Maintain High Standards

By the time this article goes to print, a lot could change, so there’s no apparent use in guessing what will come of the next Repeal and Replace efforts or what’s happening at Main Justice. Nobody knows. The only certainties from Washington are that there will be change in the payment and insurance models, and that there will be more reports of arrests and prosecutions for alleged fraudulent schemes. Some practitioners express concern, but physician quality and innovation do not have to suffer because of these changes in law because physicians maintain high standards.

Neither Obamacare nor Ryancare nor Trumpcare nor the next iteration will actually change health care. Instead, they guide how health care services are paid. Payment certainly can influence quality, just as who pays for care can perhaps impact patient compliance. But quality care is neither guaranteed nor premised on any particular actual or proposed national structure. These laws do not provide anyone health care. You do, as physicians and nurses and hospitals. The Medical Association began with 30 physicians having a common goal of higher standards in an era with no insurance market at all, nor anesthesia like we know it today. It has always been appropriate for physician entrepreneurship to drive innovation and quality care with it, but there are limits.

The limits have always been there. Whether the changes of today will raise or lower the standard of care within any specialty, or chill entrepreneurship and innovation, is up to each provider. Understanding the legal bounds is often difficult for physicians, and sound legal advice is crucial to success because for every one announced prosecution or indictment there are untold stories of civil corporate misdeeds and aggressive strategies where specialized counsel could have maintained the high standard.

The Department of Justice under Attorney General Jeff Sessions announced in a July 13 news conference that 412 people were charged for participating in health care fraud amounting to more than $1.3 Billion. Pharmacists in Mississippi recently pleaded guilty to fraud charges, with one admitting” that he conspired with others to select compounded medication formulas based on profitability, rather than on effectiveness or patient need,” and that he dispensed medically unnecessary medications. The other pharmacist admitted to “soliciting physicians and other medical professionals to write prescriptions without seeing patients for medically unnecessary compounded medications dispensed by the pharmacy.”

In Virginia, “[a] medical doctor and entrepreneur was sentenced to [10 years] in prison . . . for defrauding his former company’s shareholders and for failing to account for and failing to pay employment taxes.” Ohio-based companies and their executives recently “agreed to pay approximately $19.5 million to resolve allegations pertaining to the submission of false claims for medically unnecessary rehabilitation therapy and hospice services to Medicare,” not that the therapy wasn’t performed or quality care – just that it was excessive and driven by profit over patients. Louisiana clinical psychologists were sentenced for a $25.2 million Medicare fraud scheme involving both unnecessary therapy and therapies never performed. A Florida physician pleaded guilty for his role in pain pill diversion and Medicare fraud scheme. An Alabama federal court enjoined a pharmacy from “distributing adulterated, misbranded and unapproved new drugs in violation of the federal Food, Drug, and Cosmetic Act.” A Tennessee physician settled false claims allegations of distributing and billing Medicare for drugs that had not been FDA-approved. This is all according to the Department of Justice in just the last month. Expect more, whether it’s from General Sessions or a successor.

These headlines should educate rather than frighten the physician entrepreneur with high standards. Each case can educate an intelligent professional that while billing guidelines and corporate laws may have positive or negative impacts on quality, usually indirectly, your standard of care owed to your patient and your business partners does not have to regress. These providers who fell into trouble with the Department of Justice may truly be outliers.

The Virginia “physician and entrepreneur” sentenced in July abused his investors’ trust, stole their money, and provided fraudulent financial statements. That’s an extreme case, perhaps, but consider the same case but where the physician and his investors lost trust in each other purely because of a lack of communication after a series of misunderstandings, and maybe some ego or fear. Perhaps the misunderstandings were fueled by further misunderstandings of medicine by the investors and misunderstandings of business by the physician. But I speculate on a hypothetical ripped from these DOJ headlines. Further, though, consider where the physician did not intend to steal anything but made blindly ignorant mistakes because he failed to ask for help or just maintained business as usual despite corporate changes. Consider the same story but where the financials were not intentionally fraudulent but in error or premised on aggressive billing practices, or an unwillingness to fully engage accountants for their services to pinch pennies. These seemingly more benign circumstances could be all too common, aggravated further by ego and competing visions or interests, and if unchecked and don’t make the DOJ alert then they could also lead to civil lawsuits.

A health care lawyer can answer questions and guide physicians to maintain high standards. The honest physician in need of compounded pharmaceuticals for patients could unwittingly become a co-conspirator like the Mississippi physician. The honest clinician is being driven to cut costs and increase revenue. The honest physician is brought into seemingly prudent arrangements that can turn sour. When a physician goes beyond medicine and into business, retaining legal counsel is critical to maintaining the same high business standards as physician strives for high standards in caring for patients. Specialists and trained sub-specialists are available.

Tom Wood is a partner in the Health Care Practice Group at Burr & Forman LLP and represents health care providers in regulatory and litigation matters. Buff & Forman LLP is a partner with the Medical Association.

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Medical Association Joins 132 Medical Groups to Oppose H.R. 2276

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Medical Association Joins 132 Medical Groups to Oppose H.R. 2276

The inclusion of audiologists in Medicare’s definition of “physician” will create confusion.

In May, legislation (H.R. 2276) was reintroduced in the U.S. House of Representatives that would inappropriately provide audiologists with unlimited direct access to Medicare patients without a physician referral and amend Title XVIII of the Social Security Act to include audiologists in the definition of “physician.” More than 132 medical groups and organizations, including the Medical Association and the Alabama Society of Otolaryngology – Head and Neck Surgeons, strongly urge the U.S. House to oppose H.S. 2276.

Click here to read the letter to the U.S. House Leadership

Click here to read H.R. 2276

While audiologists are valued health professionals who work for and with physicians, they do not possess the medical training necessary to perform the same duties as physicians, nor are they able to provide patients with the medical diagnosis and treatment options they require. And, most audiologists practice in the same areas as M.D./D.O. physicians. So, claims that expanding the services provided by audiologists will somehow mitigate projected M.D./D.O. physician shortages are often unsubstantiated.

Bypassing a physician evaluation and referral can lead to missed diagnoses and inappropriate treatment that could cause lasting, and expensive, harm to patients. The Centers for Medicare and Medicaid Services has maintained a position that physician referral is a “key means by which the Medicare program assures that beneficiaries are receiving medically necessary services, and avoids potential payment for asymptomatic screening tests that are not covered by Medicare ….”

Notwithstanding the patient safety concerns associated with direct access, the inclusion of audiologists in Medicare’s definition of “physician” will create confusion regarding the qualifications and training of various health care providers. And, broadening the term “physician” to include non-physician healthcare providers encroaches on the expert status achieved by M.D./D.O. physicians. Audiologists are not physicians and should not be considered as such under the Medicare program.

Click here to read the letter to the U.S. House Leadership

Click here to read H.R. 2276

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Free AQAF Assistance: Transition to MACRA’s Quality Payment Program

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Free AQAF Assistance: Transition to MACRA’s Quality Payment Program

The Alabama Quality Assurance Foundation (AQAF), located in Birmingham, is a nonprofit consulting firm providing quality improvement assistance to the health care provider market through contract arrangements. Part of AQAF’s contract with CMS is to provide training to clinicians on the Medicare Access and CHIP Reauthorization Act (MACRA), the Merit-based Incentive Payment System (MIPS) or an Alternative Payment Model (APM). The training includes the four categories of the Quality Payment Program (QPP): quality, cost, advancing care information and clinical practice improvement activities, and the goal is to help all Alabama clinicians achieve a positive or neutral Medicare Part B Fee Schedule payment adjustment.

AQAF assists clinicians in understanding the four categories of the QPP: quality, cost, advancing care information, and clinical practice improvement activities. The goal is to help every practice choose its pace to participate so that all Alabama clinicians achieve a positive or neutral Medicare Part B Fee Schedule payment adjustment.

Technical assistance from the staff at AQAF is always FREE and available immediately by emailing TechAssist@Qsource.org, or calling toll-free Monday through Friday at 1-844-205-5540 from 8:30 a.m. to 5 p.m. CT.

For more information about QPP and to check your eligibility, visit https://qpp.cms.gov/.

 

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New Video Shows Physicians How to Avoid Medicare Payment Penalties

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New Video Shows Physicians How to Avoid Medicare Payment Penalties

The Quality Payment Program (QPP) is the new physician payment system created by MACRA and is administered by the Centers for Medicare and Medicaid Services (CMS). Because the QPP is new this year, the Medical Association of the State of Alabama and the AMA want to make sure physicians know what they have to do to participate and the QPP’s “Pick-Your-Pace” options for reporting. This is especially important for those physicians who have not participated in past Medicare reporting and programs and may be less knowledgeable about the steps they can take to avoid being penalized under the QPP.

The AMA and the Federation stressed to CMS the importance of establishing a transition period to QPP and, as a result, physicians only need to report on at least one quality measure for one patient during 2017 in order to avoid a payment penalty in 2019 under the Merit-based Incentive Payment System (MIPS).

A new short video developed by the AMA, “One patient, one measure, no penalty: How to avoid a Medicare payment penalty with basic reporting,” offers step-by-step instructions on how to report so physicians can avoid a negative 4 percent payment adjustment in 2019. On this website, ama-assn.org/qpp-reporting, there are also links to CMS’ quality measurement tools and an example of what a completed 1500 billing form looks like.

 

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CMS Proposes 2018 Payment and Policy Updates for the Physician Fee Schedule

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CMS Proposes 2018 Payment and Policy Updates for the Physician Fee Schedule

The Centers for Medicare & Medicaid Services issued a proposed rule that would update Medicare payment and policies for doctors and other clinicians who treat Medicare patients in the calendar year 2018. The proposed rule is one of several Medicare payment rules for CY 2018 that reflect a broader strategy to relieve regulatory burdens for providers; support the patient-doctor relationship in health care; and promote transparency, flexibility, and innovation in the delivery of care.

The Physician Fee Schedule is updated annually to include changes to payment policies, payment rates, and quality provisions for services furnished to Medicare beneficiaries. In addition to physicians, a variety of medical professionals, including nurse practitioners, physician assistants, and physical therapists, as well as radiation therapy centers and independent diagnostic testing facilities, are paid under the Physician Fee Schedule.

This proposed rule would provide greater potential for payment system modernization and seeks public comment on reducing administrative burdens for providing patient care, including visits, care management, and telehealth services. The rule takes steps to better align incentives and provide clinicians with a smoother transition to the new Merit-based Incentive Payment System under the Quality Payment Program (QPP). The rule encourages fairer competition between hospitals and physician practices by promoting greater payment alignment, and it would improve the payment for office-based behavioral health services that are often the therapy and counseling services used to treat opioid addiction and other substance use disorders. In addition, the proposed rule makes additional proposals to implement the Center for Medicare and Medicaid Innovation’s Medicare Diabetes Prevention Program expanded model starting in 2018.

These updates would help reduce regulatory burdens and allow practitioners to improve outcomes based on the unique needs of their patients. In addition to the proposed rule, CMS is releasing a Request for Information to welcome continued feedback on the Medicare program. CMS is committed to maintaining flexibility and efficiency throughout Medicare. Through transparency, flexibility, program simplification, and innovation, CMS aims to transform the Medicare program and promote the availability of high-value and efficiently-provided care for its beneficiaries. This will inform the discussion on future regulatory action related to the Physician Fee Schedule.

Click here for a fact sheet on the proposed rule.

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Taking CDI Into the Physician Office Setting

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Taking CDI Into the Physician Office Setting

 

CDI, or Clinical Documentation Improvement, is as familiar to physicians who practice in the hospital as other acronyms such as ICU, OR, ED – but in the physician office, CDI is relatively unknown. However, with the implementation of the Merit-Based Incentive Payment System, or MIPS, CDI in the physician office will become imperative.

Most physicians will fall under the MIPS provisions of MACRA, the Medicare Access and CHIP Reauthorization Act. CMS estimates that of the 1.3 million providers under MACRA, 1.2 million will be under the MIPS program. The Quality component of MIPS is familiar to most physicians, as it is similar to the previous Physician Quality Reporting System. One new aspect of MIPS, however, is the Resource Use or Cost. This component will be 10 percent of the physician’s MIPS score in 2018, increasing to 30 percent in 2019 and beyond. The Cost score will be derived from claims data and will be based on the CPT and ICD-10-CM codes billed. Correct and specific ICD-10-CM coding will be key to physician reimbursement in this model. Medicare, and other payers implementing similar reimbursement strategies expect that a patient with a certain diagnosis will incur an estimated cost. If the cost to treat the patient far exceeds the estimate, then the physician’s Resource Use/Cost score will be low – he/she will be considered to be an inefficient physician.

A specific example to illustrate this:  The physician treats a patient with diabetes. The only code he bills for this patient is E11.9 – Type 2 diabetes mellitus without complications.  However, this patient has diabetic retinopathy, diabetic neuropathy, and diabetic chronic kidney disease. The payer’s estimated annual cost for a patient with diabetes with no complications is $1,400, but this patient incurs much higher costs due to his complications.  The physician, therefore, appears to be inefficient, and his Resource Use/Cost score will suffer. The payer’s estimated cost for a patient with diabetic chronic kidney disease is $4,300. Had the physician coded as specifically as he could have, E11.319 for diabetic retinopathy, E11.40 for diabetic neuropathy, and E11.22 for diabetic chronic kidney disease, the higher cost would have been expected, and the physician would not be penalized for the care he is rendering.

One hindrance to CDI in the physician office setting is the use of electronic medical records and the implementation of “charge passing”, codes transmitting directly from the EMR into the practice billing system. Physicians may not choose the most specific, or even the most accurate, diagnosis code, but once those codes are passed onto the claim and filed to Medicare, there is no changing or correcting that information. Corrected claims will not be accepted for this purpose. Some practices use coders to review these claims before they are actually filed.  This usually does not involve 100 percent review of the documentation, but it would allow some coding errors to be caught. For example, if a coder noted the following diagnoses on the claim:  E11.9, N18.5, G62.9, he would be prompted to discuss with the physician that N18.5 – chronic kidney disease, stage 5, and G62.9 – neuropathy, are considered to be diabetic complications and should be coded as such. And if a coder is familiar with coding guidelines, understanding that certain diagnoses require additional codes, then when she notes G30.9 – Alzheimer’s disease on the claim, she can query the physician as to which additional code is appropriate, F02.80 – dementia in underlying disease without behavioral disturbance or F02.81 – dementia in underlying disease with behavioral disturbance.

This may require additional diagnosis coding training for physician office coders, and it will almost certainly require a change in mindset. Physician coders have focused on what is documented with the mantra “Not documented, not done.” But CDI requires a similar focus on seeing what is not documented, what should be there, what is likely true for that patient – and then querying the physician.

Electronic medical records have also contributed to some of the errors seen in that physician may not have been trained properly in diagnosis documentation and coding before having access to what is essentially the entire ICD-10-CM book in their EMR. The ICD-10-CM descriptions may not match the language the physician uses, although the code is correct. For example, in ICD-9-CM, the code for depression, unspecified was 311, and the description was Depressive disorder, not elsewhere classified. In ICD-10-CM, the code for depression, unspecified is F32.9, and the description is Major depressive disorder, single episode, unspecified. Physicians may not be able to identify the appropriate code without further diagnosis education. EMR vendors and office staff may try to set up shortcuts to assist the physicians in choosing the appropriate diagnosis code and create further issues. Two recent errors I have seen in my own auditing practice:  1.) physicians coding Crohn’s disease with small bowel obstruction when they intended to code for small bowel obstruction, unspecified and 2.) physicians coding psychophysiologic insomnia when they intended to code chronic insomnia. CDI in the physician office setting must include a detailed review of the ICD-10-CM code descriptions in the EMR.

CDI in the physician office setting does not have to be as formal a process as that seen in the hospital – it can be informal discussions with the physicians. It can be accomplished through real-time shadowing or end-of-day review, but it must occur before the claim is filed. A simple CDI process could look something like this:

  • Coder reviews record for correct coding based on physician documentation.
  • Coder talks with nurse and physician about code choices.
  • Coder identifies incorrect codes chosen – discovers confusing language in ICD-10 description.
  • Coder reviews with physician and makes changes in code descriptions to assist physician in most specific and correct coding.

The keys for coders will be continuing education, which may be in the form of informal chats with the physicians and clinical staff, review of ICD-10-CM guidelines and Coding Clinic guidance, review of medical policies which can be used to help guide physicians in documenting. And perhaps most importantly, respect for the physician’s priorities. The physician’s foremost interest is care of the patient, and CDI is simply helping the physician to understand that how he documents matters and providing the assistance he needs to make it so.

References

Medicare Quality Payment Program

Kim the Coder (also known as Kim Huey, MJ, CCS-P, PCS, CHC, CPC, CPCO, COC) works with clients to improve coding and documentation of services and to ensure compliance with Medicare and insurance company regulations. Ms. Huey is available for on-site visits for auditing and education as well as for on-the-record audits and general coding and reimbursement questions.

 

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CMS Updates Proposed Rule for MACRA; Eases Burden for Some Physicians

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CMS Updates Proposed Rule for MACRA; Eases Burden for Some Physicians

The Centers for Medicare & Medicaid Services has unveiled a 1,058-page proposed rule updating the Medicare physician payment system implemented under the Medicare Access and CHIP Reauthorization Act of 2015 with changes to make it easier for small independent and rural practices to participate.

The proposed rule would make changes in the second year of the Quality Payment Program as required by MACRA. According to a statement from CMS, the goal is to simplify the program, specifically for small, independent and rural practices, while ensuring fiscal sustainability and high-quality care within Medicare.

“We’ve heard the concerns that too many quality programs, technology requirements, and measures get between the doctor and the patient,” said CMS Administrator Seema Verma. “That’s why we’re taking a hard look at reducing burdens. By proposing this rule, we aim to improve Medicare by helping doctors and clinicians concentrate on caring for their patients rather than filling out paperwork. CMS will continue to listen and take actionable steps towards alleviating burdens and improving health outcomes for all Americans that we serve.”

The proposal will allow for the exemption of small providers participating in the program by increasing the low-volume threshold to $90,000 or less in Medicare Part B charges or 200 or less Medicare patients annually. The original threshold was $30,000 in Medicare Part B charges or 100 Medicare patients. The agency believes the move will exclude about 134,000 clinicians from MIPS.

American Medical Association President David Barbe released a statement commending the CMS for hearing the concerns of practicing physicians. “Not all physicians and their practices were ready to make the leap, and many faced daunting challenges. This flexible approach will give physicians more options to participate in MACRA and takes into consideration the diversity of medical practices throughout the country,” he wrote.

The news may come as a relief for some clinicians. In March, Healthcare Informatics found 43 percent of more than 2,000 providers stated they needed help with MACRA preparation while 30 percent said that are not prepared at all. However, after exclusions, CMS estimates 36 percent of clinicians will be eligible for participation in 2018.

The American Academy of Family Physicians stated the regulation would help improve family physicians’ ability to participate in payment reforms successfully.

“We’re pleased that, consistent with the Department of Health and Human Services’ directive, CMS has taken steps to reduce administrative and regulatory burden,” John Meigs Jr., M.D., president of AAFP, said in the statement. “We’re equally pleased that CMS agreed with the AAFP recommendations on medical homes. For example, the financial risk borne by medical homes rolls out more slowly, providing more time for family physicians to move toward full participation in the Advanced Payment Model track. Equally important are the significant steps to reduce risk for practices of all sizes in the MIPS program.”

 

New Quality Payment Program Resources Available

The Centers for Medicare & Medicaid Services revamped the look of the Quality Payment Program website and posted new resources to help you successfully participate in your first year of the Quality Payment Program. READ MORE

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A Refresher in the Medicare Claims Appeals Process…

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A Refresher in the Medicare Claims Appeals Process…

With the increased audit activity we are seeing among the alphabet soup of Medicare contractors – RACs, ZPICs, SMRCs, CERTs, etc. – now appears to be a good time for a refresher on the Medicare claims appeals process. Due to this increased audit activity, more and more claims are being denied, both under pre-payment review and post-payment review. This article provides an overview on the Medicare claims appeals process, as well as some tips and pointers to keep in mind.

Request for Redetermination

A request for redetermination, the first level of appeal, must be filed within 120 days of receipt of a demand letter from the Medicare carrier (or, if no demand letter is received, within 120 days from the date a Medicare remittance advice shows a claim denial). If the request for redetermination is filed within the shorter time frame of 30 days, recoupment will not be initiated. If the request for redetermination is filed after the 30-day period, recoupment may be initiated, but will be stopped once the appeal has been filed. Interest begins to accrue on the 31st day and continues to accrue, even if an appeal is filed, until the overpayment is repaid or an entirely favorable decision is rendered. Thus, the only way to avoid the accrual of interest completely is to repay the overpayment before the 31st day. However, you still retain appeal rights even if the alleged overpayment has been repaid — you just have to go through the hassle of trying to get the money back from Medicare if a favorable decision is eventually rendered.
To ensure that all the relevant information is included, send a cover letter containing your arguments (with supporting documentation), as well as the request for redetermination form available at https://www.cahabagba.com/part-b/claims-2/appeals-2-2/.

The first level of appeal is reviewed by the applicable Medicare carrier, which for physicians practicing in Alabama is Cahaba GBA. The Medicare carrier has 60 days to render a decision.

Request for Reconsideration

A request for reconsideration, the second level of appeal, must be filed within 180 days of receipt of a decision by the Medicare carrier on
the request for redetermination filing. If the request for reconsideration is filed within the shorter time frame of 60 days, recoupment will not be initiated. If the request for reconsideration is filed after the 60-day period, recoupment may be initiated, but will be stopped once the appeal has been filed. Interest will continue to accrue, even if an appeal is filed, until the overpayment is repaid or an entirely favorable decision is rendered. Importantly, all information must be presented at the request for reconsideration level of appeal, as new information is generally not allowed to be presented at the following levels of appeal.

To ensure that all the relevant information is included, send a cover letter containing your arguments (with supporting documentation), as well as the request for reconsideration form available at https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS20033.pdf.

The second level of appeal is reviewed by the applicable Qualified Independent Contractor (“QIC”), an independent party hired by Medicare to review second level appeals. The QIC has 60 days to render a decision.

Administrative Law Judge

A request for a hearing before an Administrative Law Judge (“ALJ”), the third level of appeal, must be filed within 60 days of receipt of a decision by the QIC on the request for reconsideration, assuming the monetary thresholds are satisfied. Importantly, there is no opportunity to stop recoupment at this level of appeal. Thus, recoupment will begin and will continue until a favorable decision is rendered or until the full amount of the overpayment and accrued interest has been offset. Interest will continue to accrue at this level of appeal until the overpayment is repaid, offset through recoupment, or an entirely favorable decision is rendered.

To ensure that all the relevant information is included, utilize the ALJ hearing request form available at https://www.hhs.gov/about/agencies/omha/filing-an-appeal/coverage-and-claims-appeals/request-an-alj-hearing/index.html.

The ALJ hearing is usually conducted by telephone or video conference. By regulation, the hearing is supposed to take place and a decision rendered within 90 days of the appeal request. However, due to backlogs at the ALJ level, it is currently estimated that appeals will not be heard by ALJs for approximately 6-8 years, unless there is Congressional action to resolve the backlog. There is an option to escalate the appeal to the next level if a decision is not rendered timely in light of this delay. However, the success rate for providers at the ALJ level is relatively high, so bypassing this level of review is not always in the provider’s best interest. Nonetheless, despite the delay by the ALJ office, recoupment will continue.

Medicare Appeals Council

A request for review by the Medicare Appeals Council (“MAC”), the forth level of appeal, must be filed within 60 days of receipt of a decision from the ALJ, assuming the monetary threshold is satisfied. The MAC is supposed to render a decision within 90 days. However, due to backlogs, MAC decisions are also taking longer to be issued. There is an option to escalate the appeal to the next level if a decision is not rendered timely. However, such escalation is not always in the best interests of providers.

Judicial Review

A request for judicial review by the appropriate federal district court must be filed within 60 days from receipt of the MAC decision, assuming the monetary threshold is satisfied. From this point, the judicial system will oversee the proceeding.

A couple of points to keep in mind with respect to Medicare claims appeals. Be proactive – review the RAC website for approved audit issues, as well as the most-recent OIG Work Plan for target issues. Develop a formal intake and review process for records requests and demand letters. Always respond to records requests in a timely manner, as the failure to do so will result in an automatic claim denial. Keep track of denied claims and look for patterns. Determine corrective action to take, if applicable, and appeal as necessary and appropriate. If you appeal, file everything by a trackable delivery method and keep copies of all documents that are filed and received. Always ask for confirmation in writing when receiving advice or instruction from the applicable review body.

While the claims appeal process can be frustrating, time-consuming, and costly, providers tend to have a high degree of success. However, many providers simply pay the overpayment amount without challenging the finding due to the associated time and expense. Depending on the amount of the overpayment and the frequency with which you believe the pertinent issue has occurred within your practice, spending the time and effort to appeal may be beneficial.

Article contributed by Kelli Fleming, a partner at Burr & Forman LLP and practices exclusively in the Birmingham office within the Health Care Industry Group. Burr & Forman, LLP is a Bronze Partner with the Medical Association.

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