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There are five levels of Appeal available to providers that receive a
notice of overpayment from Medicare.
In most cases the first two levels are going to be the most critical for any
provider to understand.
The first level of appeal is something called a request for free determination
it goes directly to the Centers for Medicare & Medicaid Services
CMS, and the second level appeal is called a request for reconsideration
and it goes to someone called a qualified independent contractor.
This is a review board that's independent from CMS.
The first two levels are critical for providers to understand because first
this is the only opportunity that providers have to submit
information records expert reports in support of their
appeal of this notice of overpayment. Once you get past these first two levels
there's no more opportunity to
amend the record, to supplement the record or
to make any argument in support of your position. The other critical factor is that
once these two levels of appeal have been exhausted
medicare has the right to start taking those alleged overpaid funds
out of the providers future Medicare payments so if the
overpayment isn't paid in a lump sum medicare goes ahead and just takes it out of
future payments
and the provider really has no recourse unless the
appeals overturned at future time by
a future level of appeal. So after these first two levels
is something called review by ALJ an Administrative Law Judge.
The ALJ is bound by the record
and the faxes they've been presented at the first two levels and has to base
its decision on the information presented.
At the fourth level of Appeal you have an HHS
Appeals Council the Appeals Council is going to look at the decision that the
ALJ
and is really going to be focused on things like issues of law and procedural defect
Once the four levels of appeal have been exhausted
the provider has one more alternative which is where the provider goes to
a judge before a federal district court and you're really
initiating a lawsuit at that point just like you would in any other case
and you're having the record reviewed but again you're bound by whatever
documents and information were submitted at those first two levels of appeal
If you'd like more information about
any of the five levels of Appeal or Medicare appeals in general
you can visit us at www.businessandhealthlaw.com
Or you can order a complimentary copy of my book a physician's guide.