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Is a Medicare Appeal Worthwhile?

If you are dissatisfied with a denial of payment by your Medicare contractor, you can appeal the decision. The Centers for Medicare & Medicaid Services (CMS) recently announced attempts to streamline the process by no longer requiring signatures, thus enabling documents to be submitted in a more efficient, streamlined manner. The appeals process continues to feature five levels of appeal, each of which have a deadline. To initiate the first level entitled “Redetermination,” for example, you need to file the appeal within 120 days after receiving the remittance.

Many practices report success related to having denials overturned. For those practices that are still stuck in the appeals process, the third level of appeals is managed by the Medicare Office of Hearing and Appeals. It is so backlogged – the turnaround time in 2018 was a remarkable 1,321 days - that CMS opened a low-volume appeals initiative last year. This featured payment of 62% of billed charges for appeals less than $9,000, just to get them out of the queue. A federal judge recently issued a warning to CMS to reduce the backlog by 2020, so many are projecting another payout soon.

Although the process isn’t easy, if you feel that your claims were not paid fairly, appealing a Medicare claim is possible. For simple, step-by-step instructions, see Medicare’s guide to submitting an appeal.

For more information about the May 2019 changes to the appeals process, visit the Rules and Regulations page here.

About The Author

Elizabeth Woodcock is the founder and principal of Woodcock & Associates. She has focused on medical practice operations and revenue cycle management for more than 25 years. She has led educational sessions for a multitude of national professional associations and specialty societies, and consulted for clients as diverse as a solo orthopaedic surgeon in rural Georgia to the Mayo Clinic. She is author or co-author of 17 best-selling practice management books, to include Mastering Patient Flow and The Physician Billing Process: Avoiding Potholes in the Road to Getting Paid. Elizabeth is a Fellow in the American College of Medical Practice Executives and a Certified Professional Coder. In addition to a Bachelor of Arts from Duke University, she completed a Master of Business Administration in healthcare management from The Wharton School of Business of the University of Pennsylvania. She is currently a doctoral student at the Bloomberg School of Public Health of Johns Hopkins University.

The contents of The Sentinel are intended for educational/informational purposes only and do not constitute legal advice. Policyholders are urged to consult with their personal attorney for legal advice, as specific legal requirements may vary from state to state and/or change over time.

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