Medicare Audits and Appeals

When Medicare conducts an audit of a provider and concludes that an overpayment has occurred it will attempt to recoup that overpayment. This article will discuss the overpayment appeals process.

There are five levels of appeal, each of which is considered a completely new examination of the audit and determination. Unlike a judicial appeal in which the appellate court often reviews the lower court only for plain error or an abuse of discretion, these Medicare appeals are independent determinations and not tied to the prior overpayment determination.

After an initial finding of an overpayment, the first level of review is called a redetermination. A redetermination is performed by an independent Medicare Administrative Contractor (MAC). Redeterminations must be filed within 120 days of the initial determination. Redetermination decisions should be issued within 60 days.

If the redetermination is unsuccessful, the second level of appeal is called a reconsideration. A reconsideration is performed by a Qualified Independent Contractor (QIC), such as C2C. The appeal must be received by the QIC within 180 days of receipt of the redetermination decision. All evidence must be submitted to the QIC, since the provider will not be able to supplement the record without good cause if the provider wishes to appeal the QIC’s determination to the next level.

The next level of appeal is before an administrative law judge. Unlike the prior appeals, these are conducted by the U.S. Department of Health & Human Services (HHS) Office of Medicare Hearings and Appeals (OMHA). Here the provider is afforded the opportunity to appeal via video teleconference, telephone, or in person. Appeals to an administrative law judge must be filed within 60 days of receipt of the decision from the QIC. Administrative law judges’ decisions are typically issued within 22 weeks.

If the provider is still unsatisfied with the recoupment decisions, the provider may continue the appeal before the Medicare Appeals Council. The Medicare Appeals Council review is conducted by the HHS Departmental Appeals Board. A request for review by the Medicare Appeals Council review must be filed within 60 days of the administrative law judge’s decision. Although the Medicare Appeals Council is required to issue an opinion within 90 days, due to the current backlog of appeals a decision may take more than 2.5 years.

Finally, the fifth level of appeal is in U.S. District Court. These proceeding must be filed in federal court within 60 days of the Medicare Appeals Council’s decision.

To discuss representation regarding filing an appeal to a recoupment decision contact Mike Rosenblat at 847-480-2390 or mike@www.rosenblatlaw.com