As a health care provider, participating in Medicare can help expand your practice and facilitate payments, but it can also expose your practice to greater scrutiny.
Medicare Recovery Audit Contractors (RACs) are vigilant in their hunt for fraud, waste, and improper payments; even providers making good-faith compliance efforts may become the subject of an audit. Worse, the findings of your audit may be unfavorable and/or incorrect.
If you disagree with the results of a RAC audit, you have 120 days from the date you receive them to file a written appeal and enter the five stages of the appeal process. At each stage of appeal, you will need to adhere to strict deadlines. Missing a letter or deadline could put your practice in jeopardy.
Understanding the 5 Stages of Medicare Appeal
1. The first level of appeal is called a Medicare Administrative Contractor (MAC) Redetermination. At this level, you submit an appeal in writing using the Medicare Redetermination Request Form (CMS-20027). You have 120 days to file your request.
2. The second level of appeal is called a Qualified Independent Contractor (RIC) Reconsideration. If you disagree with the MAC redetermination consideration, you have 180 days from the date you receive your Medicare Redetermination Notice (MRN) to submit your Medicare Reconsideration Request Form (CMS-20033).
3. The third level of appeal is called an Office of Medicare Hearings and Appeals (OMHA) Disposition. At this level, you will request an Administrative Law Judge (ALJ) hearing. If you want to escalate your appeal to the OMHA, you have 60 days from the day you receive the reconsideration decision letter to request an ALJ hearing in writing.
Please note: Medicare assumes you have received your letter within 5 days of the notice date. If you can prove that you did not receive the letter within this time frame, your deadline may be extended to reflect the date you actually received the letter.
4. The fourth level of appeal is called a Medicare Appeals Council (Council) Review. The Council is part of a government appeals board and is the last step of the appeals process before litigation. You must request your Council Review in writing within 60 days of receiving your OMHA decision or dismissal.
Please note: Medicare assumes you have received your OMHA decision or dismissal within 5 days of the notice date. If you can prove that you did not receive your OMHA documents within this time frame, your deadline may be extended to reflect the date you actually received the documents.
5. The fifth level of appeal is a U.S. District Court Judicial Review. This option becomes available to you when you disagree with the Council decision. When you request a Council Review, the Council has 180 calendar days to issue a final decision. If you do not receive a final decision within this time frame, you can escalate your appeal and request judicial review.
You have 60 days from the date you receive the Council decision to request a judicial review. If the Council has exceeded 180 calendar days without issuing a final decision, your 60 days begins tolling on the date the Council’s decision-making authority expires.
For example, if you submit a request for Council review on Thursday, October 7, 2021, and the Council does not get back to you by Tuesday, April 5, 2022, you have until Saturday, June 4, 2022, to request a judicial hearing.
To better understand the Medicare Appeal Practice, please see this guide from the U.S. Centers for Medicare & Medicaid Services (opens a PDF in a new window).
You can also read our blog, “An Undue Burden? The 5 Levels of Medicare’s Standard Appeals Process.”
What Happens If I Miss a Deadline in the Medicare Appeals Process?
Medicare can make mistakes, and so can you. If you miss a deadline in the Medicare appeals process, you likely have a valid reason.
You can defend your right to appeal with the help of an attorney, especially if Medicare’s original allegations were unwarranted, or you can prove you did not receive important paperwork from Medicare on time.
Unfortunately, “I didn’t read the mail,” or “my administrative staff did not give me the notice,” are not acceptable defenses.
Nevertheless, there are a few valid defenses, and our attorneys at Hendershot Cowart P.C. can help you identify any that apply – and use them to protect your practice. Collectively, our attorneys have been handling cases like yours for more than 100 years, and we strive to exceed your expectations.
Don’t suffer Medicare exclusions, revocations, or other consequences because of RAC and MAC errors. Instead, call our firm at (713) 909-7323 or contact us online to learn what our attorneys can do for you.