Guest Column: No isn’t always the last word; appeal denials

Some Medicare Part A denials can be reversed

By Linda Fotheringill
Fotheringill & Wade, LLC

So your carrier/intermediary has denied too many Part A Medicare claims, and you are ready to take action. That’s great. The Medicare Part A appeals process currently found in chapter 42, Code of Federal Regulations (C.F.R.), Part 405.701-405.753 only appears to require a rocket scientist to decipher; in actuality, it’s pretty straightforward. Generally speaking, follow the steps below and you stand an excellent chance of overturning the denial:

Carefully read the carrier’s initial determination.

The written notice of the carrier/intermediary’s determination should state in detail the basis for the determination and should inform the provider of its right to reconsideration. The notice also should state that the carrier/intermediary has made a finding that the patient did not know, or could not reasonably have been expected to know, that the expenses incurred for the services were not reimbursable. Regardless of whether the denial was administrative or clinical in nature, determine if the denial was unfair or inappropriate, and formulate your response.

File a request for reconsideration within 60 days.

Your request for reconsideration must be filed in writing within 60 days of receipt of the written notice of determination. You should include an explanation of why the initial determination was wrong, along with supporting documentation such as medical records, hospital account notes, case management notes, and any other evidence that will help to show the inappropriateness of the initial determination. Your written request for reconsideration should be filed at an office of the Social Security Administration or the Centers for Medicare & Medicaid Services (CMS), or, in the case of a qualified railroad retirement beneficiary, an office of the Railroad Retirement Board. (If you miss the 60-day requirement, there is a chance that CMS will grant an extension if you can show "good cause" for the delay.)

Carefully read CMS’ notice affirming or revising the initial determination.

CMS will make a determination affirming or revising the initial determination and advise you by written notice, stating the specific reasons for the reconsidered determination and advising your hospital of your right to a hearing if the amount in controversy is $100 or more. If the reconsidered determination is unfavorable and the amount in controversy is $100 or more, plan to request a hearing. Remember that under certain conditions, the dollar amounts of several claims may be aggregated to meet the threshold. Likewise, regardless of the amount in controversy, multiple claims with similar issues could be aggregated for ease of handling.

File a request for hearing within 60 days.

The written request for hearing must be filed within 60 days of receipt of the reconsidered determination at an office of the Social Security Administration, the CMS, or with an Administrative Law Judge (ALJ), or, in the case of a qualified railroad retirement beneficiary, an office of the Railroad Retirement Board. If you miss the 60-day deadline, an exception can be made if "good cause" is shown. Once you are at the level of requesting a hearing, it would be helpful, although not necessary, to have your in-house counsel handle the appeal or to retain a qualified attorney to do so.

There are several factors favorable to the provider in the hearing process:

— First, providers may present their case at the hearing and be represented by attorneys and expert witnesses. Medicare is represented only by a written record. Although an administrative law judge can invite a Medicare contractor to a hearing, this rarely occurs. When invited, contractors typically will send a physician or a nurse, rather than an attorney, to represent them.

— Providers are allowed to rebut testimony contained in the contractor’s written record.

— ALJ decisions do not set precedent. Further, the Departmental Appeals Board, the highest level of Medicare administrative appeals, does not have precedent-setting authority.

Inappropriate denials more than likely will be overturned if your hospital utilizes the Medicare appeals process. Accordingly, proactive providers should incorporate the Medicare appeals process in their denial management strategy.