The Healthcare Provider's #1 Medicare Audit Defense & Medicare Appeals Resource
Medicare Audit Defense - Medicare Appeals - CMS Program Integrity Resources

Providers work hard and deserve payment for insuring exceptional care and services to Medicare beneficiaries.  Yes, there are rules, but the system of rule-making and implementation is extraordinarily dynamic.  The federal government has 10,000s of employees and contractors assisting in changing and enforcing the rules, it is simply impossible for a single provider to keep pace. 

Over the past 25 years, Jackson Davis HealthCare professionals have assisted providers and attorneys nationwide in defending 1,000s of Medicare overpayment issues.  As your unwavering advocate, Jackson Davis leads the nation in building winning Medicare appeals cases.  Jackson Davis is the undisputed leader in understanding and synthesizing Medicare rules, regulations and guidance - no one understands Medicare coverage criteria better than we do - and we prove it everyday.

Do you realize that there are actually "consulting experts" that are on record saying that Medicare provides only guidance and it really doesn't have medical necessity or documentation rules that you must follow?  Have you ever heard a snake oil salesman imply that medical necessity is in the eye of the beholder or that are ways to circumvent Medicare coverage criteria?  Simply put, Jackson Davis is on your side and our honesty, knowledge, experience and passion makes us your best partner for developing winning Medicare appeals.
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Turning the Page - The Winning RAC Appeals Strategy

With the Medicare RAC audit program being in full force nationwide, providers are preparing for RAC audit denials and setting in motion a series of processes to successfully address RAC 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 RAC 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) and potential Medicare fraud implications, 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 RAC appeals, and (3) how do we stop CMS audit outcomes from turning into Medicare fraud allegations.

Within the  RAC 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 RAC appeals and the very real possibility of RAC audit outcomes becoming potential Medicare fraud issues.  Here are a handful of things to consider when tackling RAC 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" RAC 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 RAC 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 RAC 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 RAC appeals

Remember, the Medicare Appeals Council is the last administrative step in the Medicare appeals process.  The Medicare 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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Medicare Audits / Medicare Appeals Resources

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

RAC Appeals - The Medicare Appeals Brochure
RAC Appeals - Appeals Process Diagram
RAC Appeals - Limitation on Recoupment

Medicare Appeals - Denials & Overpayment Determination

Jackson Davis works directly with providers and partners with leading Medicare law firms to build winning Medicare appeals cases and reduce the anxiety of potential Medicare fraud allegations.  The following information MUST be included with your request for all Medicare Appeals - RAC appeals, ZPIC appeals, DOJ appeals, MAC appeals, MIC appeals or individual Medicare beneficiary appeals. 
 
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.

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.In summary, time frames relating to the filing of appeals during the first 2 steps of the Medicare appeals process have not changed (i.e. 120 days to file for redetermination and 180 days to file for reconsideration).  However, in order to stop the automated recoupment of overpayments, providers MUST file Medicare appeals within 30 days for redetermination and within 60 days for reconsideration.