Tips For Managing Medicare Claims Appeals

Managing Medicare claims appeals continues to be a heavy burden for providers.  In light of the Office of Medicare Health Appeals (OMHA) announcement of a two year moratorium on the acceptance of new cases for ALJ appeal, the burden has only increased.  Providers challenging Medicare claims denials who believe they have a meritorious case can expect to face a huge backlog for years to come.  However, providers can do a number of things to prevail against these barriers.  First, providers must avoid making common mistakes that would lengthen the appeal process or even doom an appeal before it begins.

Best Practice Tips

It is clear that bad practices can lead to increased delays in decisions, and worse, contribute to undesirable decisions.  There is no “magic formula” for securing a timely and favorable decision from an ALJ.  However, there are a variety of sound practices, techniques, and methods that experts utilize to assist in expediting claims appeals and to improve the chances for a timelier and better appeal decision.

1. At the outset, engage highly experienced expert advisors to assist in the appeals process and to avoid costly mistakes. One of the biggest problems for providers is seeking and receiving the right advice too late.

2. Properly organize evidence at the Qualified Independent Contractor (QIC) level of review. This will not only improve the chances for a favorable decision at the QIC level, but failing to do so can make it easy, at the ALJ level, to rule against claimants.

3. Ensure to properly prepare and submit the “ALJ Appeal Memorandum” or “Prehearing Brief” prior to the scheduled hearing at the ALJ level. Many submissions fall very short of expectations and lead to increased delays and/or adverse decisions.

4. Avoid excessively long and overly-detailed documents in submitting an appeal. Although this level of detail may look good to a provider, it can lead to confusion and prove damaging.  On the other hand, too short briefs and/or a lack of supporting documentation may prove too skimpy, leading to unwanted results.  Properly balancing the documents with the right kind of information is the best way to ensure the case is not put aside or ruled upon negatively.

5. Ensure to present all applicable legal authority, evidence, and technical issues in the proper form and format. Every case involves different statutory and evidentiary issues.  As such, to the extent that an appellant can provide helpful guidance and assistance to a reviewing authority in identifying the key legal authority and evidence in a case, the greater the likelihood the provider can secure a timelier and more favorable decision.

6. It is advisable to make the reviewing authority’s job as easy as possible by presenting information in the manner necessary to make a clear and decisive determination. The easier the appellate makes the reviewing authority’s job, the better the chances of a swift and solid determination.