Medicare Appeals and Regulatory Analysis

BESLER’s healthcare reimbursement services have prepared re-openings and documentation to support appeal issues and ensure corrected payments. Our core group of highly qualified and innovative consultants can work with your reimbursement department to navigate complex appeal issues.

Contact BESLER to learn more about this specialized solution.

Additional Information on Medicare Appeals

1. What are the 5 levels of Medicare appeals?
   1. First Level of Appeal: Redetermination by a Medicare Administrative Contractor (MAC)
   2. Second Level of Appeal: Reconsideration by a Qualified Independent Contractor (QIC)
   3. Third Level of Appeal: Decision by the Office of Medicare Hearings and Appeals (OMHA)
   4. Fourth Level of Appeal: Review by the Medicare Appeals Council
   5. Fifth Level of Appeal: Judicial Review in Federal District Court
2. What are the steps taken when appealing a Medicare claim?
   • Appeals follow the levels listed above and must be submitted in writing within the specified timeframe for each level. Full supporting documentation must be submitted during each level of the appeal process. If you disagree with the decision at one level, you move to the next level of appeal.
3. How successful are Medicare appeals?
   • There is never a guarantee of success with an appeal. It’s very dependent on the issue, regulatory environment, and adequacy of the documentation or issue being appealed. Another consideration is if it’s a group appeal issue. Certainly, a group appeal has the potential to carry more weight as there are many facilities that are appealing the same issue. It’s important to seek out both reimbursement and legal counsel to determine if an appeal is viable for your facility.
4. How long do Medicare appeals / disputes typically take?
   • It can range from months to years. The time it takes depends on how many levels you progress through the appeal process. Each level has to be filed within a certain range of time (1^st: 120 days, 2^nd: 180 days, 3^rd – 5^th: 60 days each), then each entity has a length of time to respond ranging from 60–180 days, and if your appeal goes to the fifth level, there is no statutory limit for a response from the Federal District Court.
5. How valuable is it to pursue a Medicare dispute? When should one pursue?
   • It would be valuable if there is a significant reimbursement impact. Section 1869(b)(1)(E) of the Social Security Act (the Act) established the amount in controversy (AIC) threshold amounts for Administrative Law Judge (ALJ) hearings and judicial review at $100 and $1,000, respectively, for Medicare Part A and Part B appeals. The benchmark for a reopening of a cost report is $10,000 or more. This should be a consideration when determining whether to pursue an appeal. Specific facility issues need to be weighed as to the amount of impact as compared to the monetary and other resources required to bring an appeal to a successful conclusion. As noted previously, any specific facility issue should be reviewed as to the availability of a group appeal for the same issue.