Hello, I’m Paul Deutsch, Carrier Medical Director for Empire Medicare Services Part B in New York. Today, I would like to discuss the appeal process when reimbursement for a claim has been denied or reduced.
The appeal process if very structured.
The first level of appeal is the redetermination (formerly a review). This takes place at the carrier level. When requesting this review you should clearly explain why you disagree with the payment decision, and include supporting documentation from the patient’s medical record. If you have been denied when billing for a new procedure, test or drug, you should also include copies of articles from the peer-reviewed literature supporting that service. You must request this redetermination as soon as possible since there is a 120-day time limit on filing these requests. It is important that you protect your appeal rights.
If you are not satisfied with the redetermination decision, your next level of appeal is the reconsideration (formerly a Fair Hearing). This process will be changing in January 2006, when the hearing will be held by a Qualified Independent Contractor (QIC) rather than by hearing officers at the Carrier.
The next level of appeal would be to an administrative law judge (ALJ), and then to the Departmental Appeals Board. Instructions for these appeals accompany the prior level decision and also have stated time limits. Failing to receive satisfaction, the final step for appeals is federal court, although this is rarely necessary.
In addition to appealing the claim, you may think that the basic policy is flawed. In those instances we welcome your input and encourage you to write to the Medical Directors, here at Empire, to explain your viewpoint. We frequently change local policy after receiving these letters. Alternatively, you may wish to take advantage of our more formal LCD-Reconsideration process. Instructions are available on the Empire website. Both approaches should include articles from the medical literature supporting your view.
We appreciate your participation in the Medicare process. Thank you.