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Appealing Medicare Denials – 5 Things You Must Know

February 11, 2014 0 Comments

Appealing Medicare denials is likely to be a reality for all outpatient therapy providers this year. Therapy over the $3700 cap is subject to 100% mandatory medical review by the Recovery Auditors (RACs) through 3/31/2013.  In fact those reviews, if not favorable, will first frustrate you, then possible anger you, then compel you to file an appeal.   Phones calls and emails today, from clients and non-clients reveal a growing frustration with the manual medical review process, some misunderstandings about the 10 day review in prepayment review states, and providers entering the appeals process that have a rude awaking on the two year backlog of appeals.  I covered that in this blog post on the ALJ Appellate Forum.  Let’s not take any more time and get right to the 5 things you must know when appealing Medicare denials.

Appealing Medicare Denials – Here are the “5”

  1. Medicare has formal appeals process, and your MAC will have interactive PDF forms and instructions to get you started.  Also check the CMS appeals website for complete rules and references.
  2. Recoupment (for post-payment review) will begin on the 41st day from the date of the demand letter if your MAC does not receive one of the following by the 30th day from the date of the demand letter: payment in full, a request for an extended repayment schedule. or a valid redetermination request
  3. If you use esMD (congratulations!) to submit to the RAC, you will have to go back to mail for the appeals process.  esMD is expanding to appeals in 2014, but we are not there yet.
  4. Organize all the documents and include a cover letter (last chance!) with a case executive summary (think of it as an excellent D/C report), a rebuttal of the denial as well as index of documents.  Strive to put items into evidence as early as you can in the appeals process.
  5. In spite of 24 – 30 month delay on ALJ hearings right now, appeal your case if you have deemed it defensible.  CMS collects data on appeals, and when you win (think positive), you will get interest on your payment.

Are you in appeals because of RAC denials?  Do you know that you will likely be in appeals because of pending ADRs?  What questions do you have?


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Nancy Beckley

Nancy J. Beckley MS, MBA, CHC: President-Nancy Beckley & Associates LLC. Compliance outsourcing, risk assessment, compliance plans, compliance training, auditing, due diligence, investigation support for therapy providers.

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