You will be lucky if you can get through life without having to fight with Medicare about a medical claim, especially if you have a chronic condition like diabetes. A Medicare claim rejection can feel like the final word, but there is a process in place to appeal such decisions.
The good news is that there are several levels of appeal, giving you opportunities to state your case. The bad news is that the process can be time-consuming and doesn’t always go in a straight line.
Appeals are most often generated by aggrieved patients who have been denied benefits, or whose benefits have been reduced or terminated. Medical practitioners, clinics, and insurance companies connected with Medicare also can appeal decisions, and doctors sometimes appeal on behalf of their patients.
These appeals follow a five-step path. The first four steps take place within the Department of Health and Human Services, with the fifth and final step taking place at United States District Court.
For appeals by a Medicare recipient of Part A,B,C and D claims, the first step is to seek a redetermination by the Centers for Medicare and Medicaid Services, the administrative arm of the Department of Health and Human Services. That request has to be brought within 120 days of the date of the initial claim determination, called a Medicare Summary Notice (MSN).
Level 1
The Medicare Program uses an outside contractor, called a Medicare Administrative Contractor (MAC), to review the claim for redetermination. The MAC can let the initial claim determination stand, modify the claim determination, or issue an entirely new determination.
At this first appeal level and the next, the review is a wide-ranging consideration of all the facts, including the medical justification for the expense for which coverage is desired, and there is no minimum loss or lack of coverage amount which has to be claimed. The time frame for issuing a decision is no more than 60 days. Expedited review is possible in some cases; in all prescription appeals, for example, the limit for decisions is seven days.
Level 2
Within the next 180 days after a decision has been reached by a MAC, you can seek review at a second level, this time for a reconsideration of the original claim denial. This is done with another outside entity called a Qualified Independent Contractor (QIC), an individual or organization retained by the Medicare Program to conduct the reconsideration and who has had no part in the first-level case.
Level 3
A recipient who doesn’t win at this level can take the case before an administrative law judge (ALJ) in the Office of Medicare Hearings and Appeals within another 60 days. These appeal judges are part of the Office of Medicare Hearings and Appeals. An ALJ reviews the entire record, and may take oral testimony or written testimony or ask for new information before reaching a decision.
An ALJ has the power to affirm the second-stage decision or overturn it and order payment of benefits. The ALJ can also send the matter back to the second level for additional evidence. The ALJ’s review amounts to a retrial of the matter based on all facts and circumstances, and a determination of the matter on the applicable law.
Level 4
The next level for a recipient dissatisfied with the ALJ’s decision is to seek a review by the Medicare Appeals Council. Once cases get to this level, the scope of review can sometimes become narrower. The Appeals Council can set aside an ALJ decision based upon an error of law, but also has the power to consider the matter anew.
Level 5
A federal statute called the Administrative Procedure Act and the Federal Rules of Civil Procedure govern the next level of appeal to a U.S. District Court. It’s at this level that claimants should engage lawyers, if they haven’t already. The review in the judicial branch becomes narrowed to whether or not DHHS acted contrary to law or contrary to the evidence in rendering the claim decision.
There is a presumption going into court that the DHHS decision was properly rendered on the facts before it, and in accordance with the law, so the burden is upon the aggrieved claimant to demonstrate otherwise. So, unlike most cases arriving at the Appeals Council, there isn’t a do-over review of the claim nor a substitution by the District Court of its judgement for that of the Appeals Council.
In practice, cases arriving in the federal district court are assigned to magistrate judges, the judges who usually rule on pretrial motions and conduct prehearing conferences. The magistrates often decide to send a case back to the Appeals Council with an opinion outlining their reasoning and an order to the Appeals Council to issue its ruling consistently with what the court has determined. The Appeals Council, in turn, may remand the matter to an ALJ for final entry of a coverage order.
There may be claims which touch narrowly on the claimant’s medical circumstances and treatment needs, and there may also be claims based upon categories of devices or drugs or methods of treatment. It’s in this latter kind of claim where a judicial ruling overturning or upholding a decision by the Medicare Appeals Council may eventually have broader implications. That’s because such rulings become binding upon the Medicare Program and its benefit contractors in similar cases.
The Centers for Medicare and Medicaid Services publish an outline of the appeals process, with links to describe each level of the process. For more information, go to https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MedicareAppealsprocess.pdf.
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