MEDICARE APPEALS PROCEDURE
Physicians who care for Medicare patients
occasionally find that their claims for payment are either denied after
submission, or may be subject to a pre-payment review of a significant
number of claims, by the local insurer contracted to process Medicare
claims. In Northern California, the National Heritage Insurance Company is
the insurer contracted by the federal government to process Medicare
claims.
A physician who seeks to appeal a
Medicare claims denial can seek an informal review or inquiry with the
insurer over the telephone. If this is unsuccessful, the physician can
obtain a formal review of the denial by the insurer over the telephone or
in writing. A physician who seeks to appeal a formal review decision by
the insurer can obtain a Medicare fair hearing with a hearing officer.
1. Review by Telephone of Denied Claims
After a Medicare claim has been denied,
the physician can call the insurer on the telephone seeking a formal
review of the denial. The physician should be prepared to provide his or
her provider identification number, the patient’s name and Medicare
number, and the date of service at issue. Claims for up to three patients
at a time can be reviewed over the telephone. The request for review over
the telephone should be made within six months of the claim denial.
Certain claim denials can be subject to
review over the telephone, such as denials for claims lacking certain
information or containing incorrect information. This includes denials for
incomplete or inadequate dates of service, diagnosis or procedure codes,
modifiers, profiles, billed amounts, or quantities billed. Claims
improperly bundled, misread, or erroneously denied as duplicate can also
be reviewed over the telephone.
No written decisions by the insurer are
made for reviews requested over the telephone.
In Northern California, the Provider Help
Line is (530) 743-1587 for reviews of denied claims over the telephone.
2. Review in Writing of Denied Claims
If the insurer continues to deny the
claim even after a telephone review, or if the physician seeks review of
claim denials involving more than three patients, the physician must write
the insurer to seek a written review of the claim. Claim denials involving
ambulances, eligibility, claims deemed too old, deductibles, missing
operative reports, test results, or invoices, or overutilization of
services requiring documentation of medical necessity, should be reviewed
in writing. The written request for review must be made within six months
of the denial. Unprocessable claims cannot be reviewed and should be
re-submitted through the normal claims processing procedure.
The physician seeking a review of denied
claim in writing should include a thorough cover letter specifically
identifying the basis for the review and including any relevant
information to assist the insurer in processing the claim.
In cases where the insurer has provided
the physician with the necessary guidance after the filing of a written
request for review, the physician should wait at least forty five days
before re-submitting the claim. If a simple correction or addition to the
claim is all that is needed, the claim may be re-submitted as a new claim.
However, re-submission as a new claim does not extend the six month
deadline for reviews of denied claims.
In Northern California, written Medicare
claim denial reviews should be addressed to Medicare Claims Review, Chico,
California 95976.
3. Medicare Fair Hearing for Denied
Claims
Many physicians find that claim denial
reviews either by telephone or in writing by the insurer are generally
ineffective and are useful only for obvious processing errors by the
insurer or the physician. In such cases, the physician’s only recourse is
to seek a Medicare fair hearing. Medicare fair hearings can be done over
the telephone, in writing, or in person at a hearing. The hearings are
conducted and decided by a Medicare fair hearing officer. Telephonic
hearings are done over the telephone at a time mutually convenient to the
hearing officer and the physician. Written hearings are done solely
through the use of letters and documents.
Physicians considering telephonic or
written hearings should consider retaining an attorney to assist in
presenting the appeal. Attorneys can assist the physician in preparing the
appeal, either by preparing the physician to make the presentation over
the telephone, appearing for the physician over the telephone, or
preparing the written documentation for the hearing. Attorneys should
submit an Appointment of Representative form from the insurer to represent
a physician at a hearing. Physicians interested in retaining counsel
should seek legal representation experienced in Medicare appeals. Some
professional liability insurers may provide legal representation for
Medicare appeals.
Physicians seeking an appeal through a
fair hearing should strongly consider having the hearing occur in-person.
Physicians should also strongly consider retaining legal counsel to
represent them at the hearing. An in-person hearing gives the physician
the best chance to personally persuade a fair hearing officer to order
payment of denied claims. An in-person hearing allows the physician to
personally testify as to why the claims should be paid. An attorney can
help the physician present the best case possible before the hearing
officer. The insurer will be represented by an employee of the insurer
and/or the insurer’s physician advisor, but is typically not represented
by counsel.
Any relevant documentation that supports
payment of the claim should be presented at the hearing. This can include
operative reports, office or progress notes, and treatment plans.
A request for a Medicare fair hearing
must involve a claim or an amount in controversy for more than $100, an
unsuccessful review of the claim by the insurer, and be in writing. The
request should be limited to claims involving twenty patients. The request
must state that the physician is dissatisfied with the outcome of the
review, and that a review is being requested. The request should also
include a copy of the claim denial and a copy of the denial of the review
by the insurer. The request should include the patient’s name and Medicare
number, date of service, and procedure code. The request must be made
within six months of the rejection of the review of the denied claim by
the insurer.
In-person hearing can occur at a
geographic location convenient to the physician because there are Medicare
fair hearing officers located throughout the state. Decisions by hearing
officers are not precedent. A hearing can be scheduled within two weeks of
the receipt of the letter from the hearing officer acknowledging the
request for a hearing.
In Northern California, Medicare fair
hearings should be sent to Medicare Part B Hearings, P.O. Box 2807, Chico,
California 95927-2807.
Physicians have reported good results in
Medicare fair hearings and are generally more successful than with reviews
by insurers.
If the amount in controversy is greater
than $50,000, a physician can request a hearing before a Social Security
Administration administrative law judge if the physician is unsuccessful
at a Medicare fair hearing. However, administrative law judges are known
to generally favor the government at administrative law hearings and are
not necessarily experienced in dealing with Medicare claims. Physicians
seeking relief at administrative law hearings should seek legal counsel
experienced in conducting discovery and appearing at administrative law
hearings.
An unsatisfactory outcome at an
administrative law hearing can be dealt with within sixty days through an
appeal for amounts greater than $500. The Medicare Appeals Council in the
Social Security Administration can hear your appeal without regard to the
decision by the administrative law judge. Physicians can also appeal
decisions by the Appeals Council involving more than $1000 by filing suit
against the insurer in federal district court.
