Medicare appeal process work flow - four steps

How Current Medicare Appeals Process Works

At the present time, appealing a Medicare denial can be a long and arduous
process, says Washington, D.C., health care attorney Alan Reider, who has represented
physicians in this situation. The appeals process currently consists of
the following levels:

Level #1: Internal review. This is a request for reconsideration of the denial
by the carrier—although not by the same individual who originally denied your
claim. You may submit documentation to support your request for internal
review, but you may not argue your position in person. It might be up to six
months from the time you submit a request for reconsideration until you get the
internal reviewer’s determination. If the internal review doesn’t resolve the matter
to your satisfaction, you can request the following:

Level #2: Fair hearing. The hearing is before a “fair hearing officer” who’s
also an employee of the carrier. (Under the Benefits and Improvement Act of
2000, or BIPA, hearing officers were supposed to be replaced by qualified independent
contractors, starting in April 2002. But Reider points out that this
aspect of BIPA hasn’t yet been implemented.) You can present live testimony
and provide supporting documents at this hearing, and there may be some dialogue
between you and the hearing officer. The fair hearing gives you a chance to answer any questions the carrier has about the service you provided. It
can take nine to 18 months from the date you request the fair hearing until
the receipt of the officer’s decision. If the results of the fair hearing aren’t
satisfactory, you could request the following:

Level #3: Formal hearing with ALJ. Although it may take 18 months
or more before you have your hearing with an Administrative Law Judge
(ALJ), depending on the case, having a hearing before an ALJ can be worth
the wait, Reider says. ALJs often overturn the decision of the carriers’ internal
reviewers and fair hearing officers, he reports. ALJs work for the Social
Security Administration and aren’t bound by the carrier’s LMRPs or even
CMS’s instructions to carriers. So with this broad discretion, they can right
wrongs they perceive in CMS and carrier policies. And the hearing process
itself permits physicians to introduce expert testimony and engage the ALJ
in a persuasive dialogue that can be beneficial to the physicians, Reider
explains. But if the ALJ’s decision isn’t what you hoped for, you can request
the following:

Level #4: Medicare Appeals Council (MAC) review. Most appeals
don’t go this far. But for physicians who have a point to make, a MAC
appeal is a possibility. The MAC reviews the record of the lower proceedings
and may consider any new evidence and legal briefs, at the appellant’s
request. The main reason to request a MAC review is to “exhaust administrative
remedies,” Reider explains—a legal term that means you must try
every other option to resolve your problem before taking the government to
court. If the MAC appeal doesn’t come out in your favor, you may sue in
federal court.