Kusserow’s Corner: Tips on Medicare Claims Appeals

I previously reported on the Office of Medicare Hearings and Appeals (OMHA) “Forum on Medicare Appeals” that outlined plans being followed to address the huge backlog of cases and the moratorium on accepted new ones. OMHA noted that failure to follow proper procedures has complicated the process and added to the delays in processing. It cited a number of things that have contributed to the problem, including:

  • Documents missing the Medicare Appeal Number
  • Inaccurate Medicare Appeal Numbers (jumbled or missing digits)
  • Mismatch of the Medicare Appeal Number and beneficiaries’ name and/or HICN
  • Requests being submitted prematurely
  • Request mailed to wrong entity
  • Timelines problems (e.g. filing within 60 days of receipt of QIC reconsideration)
  • Extension requests (Form HHS-727) filed with request and not in advance of it
  • Files bulky with documents duplicative of what OMHA receives from the QIC
  • Over bulky submissions create a storage problems and impacts on processing time
  • Additional filings after submission of the request may not connect properly or go astray

Part of the program included a discussion of best practice tips that can assist both OMHA and the provider in the appeal process. They ranged from the very simple procedural issues to more substantive thoughts. It was emphasized, however, that the simplest and most obvious tips were important, as many appellants have found their appeals sidelined for failing to follow proper directions. So, after noting the problems in the submission of appeals, OMHA offered the following suggestions and tips in submitting appeals:

  1. Prominently list Medicare Appeal Number on all requests
  2. Use track mail for all communication to OMHA
  3. Use shipping tracking numbers to verify delivery
  4. Ensure the beneficiary information matches the Medicare Appeal Number
  5. List the beneficiaries’ full HICN
  6. Include the first page of the QIC decision, or prominently list the full name of the QIC
  7. Document Proof of Service to other parties identified on reconsideration was provided
  8. Mail request via track mail to Central Operations
  9. Don’t submit evidence already submitted at a lower level
  10. If new evidence to an ALJ, not provided at a prior level, it requires written explanation
  11. A Medicare Appeal Number can only be used once to establish an ALJ record
  12. Duplicate filings offers considerable exposure to confusion of records
  13. Don’t submit a courtesy copy of the request to the QIC
  14. For complex filings for multi-beneficiary reconsideration, group hearing requests, and aggregation; submit as a single request package for assignment to a single ALJ and note on the form “Multiple”
  15. For appeal submissions, consolidate as many similar claims as possible in a single request
  16. Consider providing advance permission to sample claims to extrapolate the total
  17. File requests timely with the contractor
  18. Include all required items and sign the request
  19. Include a copy of the decision letter issued at the previous level
  20. Include a copy of the demand letter if appealing an overpayment issue
  21. Include an Appointment of Representative (AOR) form if representing a party
  22. Respond promptly to contractor requests

The Forum also addresses those cases that are appealed to the Medicare Appeal Council with best practice suggestions and tips when filing a request for review. They included:

  • Include an explanation of what part(s) of the ALJ action that is in disagreement
  • Send a copy of the request for review to each party copied by the ALJ (not simply a review is requested)
  • Notify the other parties of what, if any, supplemental material or new evidence was submitted and make it available if requested (Note: Not currently required by the Council)

For more complete list of tips and ideas, referring back to my blog entitled “Former Medicare Appellate Judge Offers Tips for Managing Claims Appeals” wherein Tom Herrmann, who retired from the Medicare Appeals Council, offered some additional advice on the subject. Taken together, all these tips have to be useful for those making Medicare appeals.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

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Copyright © 2014 Strategic Management Services, LLC. Published with permission.