Audits

Upon review of the medical record in question, for the claim that has been denied, you determine that everything you did was medically necessary. You coded everything correctly. You took copious notes. But the recovery audit contractor (RAC) has come back with a denial and informs you that they have found an overpayment. Now, you are expected to return that amount.

What is your next step, where do you go from here?

Begin discussions with the RAC

After receiving the first demand letter, set up a discussion with the RAC. A Request for discussion must be sent within the first 30 days after the date of the original decision letter. (i.e., Initial Findings letter or Review Results letter). During this discussion you can provide additional information about the patient and circumstance, and explain why they should not be seeking a recoupment from you. The RAC also gets to explain their side and why they decided the claim was overpaid.

Getting started: Fighting an overpayment decision

You have discussed your case with the RAC,however they have decided not to reverse their decision and will move forward with a recoupment. Your next step in the process is to file a redetermination request and begin the official appeal process.

There are five levels in this process:

Level 1: Request for redetermination by a Medicare Administrative Contractor (MAC)

You file an appeal with the MAC that made the first decision. You have 120 days from the date of the first letter to fill this request, but be aware that after 30 days, recoupment actions will begin. Recoupment actions can include the recovery of overpayments from payments currently due or from future claims submission. While recoupment will stop if you file a redetermination request later than 30 days from the date of the demand letter, any money already taken won’t be refunded. There is no minimum monetary requirement for filing a request for redetermination. This means your request can be for any dollar amount.

You can request a redetermination by completing Form CMS-20027 accompanied bysupporting documentation to the redetermination request.

Level 2: Reconsideration by a Qualified Independent Contractor (QIC)

If you’re not satisfied with part or all of the redetermination, you can bring in an outside reviewer called a Qualified Independent Contractor (QIC). This request must be filed within 180 days of when you receive the redetermination decision. However, you should file it within 60 days to stop recoupment. And like redetermination request, there is no minimum monetary requirement for filing a request for reconsiderations.

Follow the directions on your Medicare Redetermination Notice (MRN), which gives you the result of the first level of the appeal, and fill out Form CMS-20033.

Level 3: Hearing by an administrative law judge (ALJ)

If your level 2 actions have not been fruitful and there is still a minimum of $160 remaining in the controversy, you can request an administrative law judge (ALJ) hearing. An ALJ hearing usually takes place within 60 days of the judge receiving the request.

Most ALJ hearings are done by video-teleconference or by telephone. You can ask for an in-person hearing, but you will need to show that you have a good reason (e.g. you don’t have the technology needed). You can also ask the judge to look at your case and make a decision without having an official hearing.

For level 3 appeals you will need Form OMHA-100, Form OMHA-100A, and/or Form OMHA-104 (all PDFs). Each one fulfills a specific request so be sure to familiarize yourself with each one.

Level 4: Review by the Medicare Appeals Council within the Departmental Appeals Board (aka an Appeals Council)

If you have followed the previous 3 levels of appeal and are still unsatisfied with the results, you can request a level-4 review by an Appeals Council. This request needs to be submitted within 60 days of receiving the ALJ’s decision and you need to specify the issues and findings that you want to contest. Additionally, you need to make sure that the request also gets sent for review by any other parties who received notice of the ALJ decision, such as CMS. As with the redetermination and reconsideration requests, there is no minimum monetary requirement for filing a with the Medicare Appeals Council. You will need Form DAB-101 (PDF).

Level 5: Judicial review in U.S. District Court

You have reached the last level of appeals available to you. If you are not satisfied with the level-4 decision and there is still a minimum of at least $1,600 at stake in the controversy, you can file a level-5 appeal. You must file the request for review within 60 days of receiving the Appeals Council’s decision. Also, a level-4 case can be escalated right to level 5 if the period for the Appeals Council to complete the review has run out and they can’t issue a decision or dismissal.

You will find specific directions for requesting a judicial review in your decision letter from the Appeals Council (level 4).

Tips for successful appeals

Your appeal request won’t get you far if you don’t do it correctly. Follow these guidelines carefully:

• Meet each deadline.

• Make sure you submit all of your documentation on time, with your request. Sending in materials after you submit your request could result in the documentation not getting used.

  • In some cases, especially at the QIC level, you may be able to send in additional materials after the deadline. However, that can extend the time it takes to complete the appeal. The recoupment process (taking what you owe out of current or future claims) may begin in the meantime, and you won’t get that money back.

• Make a packet of materials, such as:

  • Medical records

  • Referral letters

  • Patient history

  • Clinical decision-making

• Date and page stamp all your materials.

• Include a title page in this packet of materials that contains an organized breakdown of what is contained in the packet. State exactly what page the specific condition is listed on in the medical record.

• Include journal articles and clinical standards supporting your medical decision-making.

• Don’t assume the QIC panel reviewing your case is made up of clinical experts. Many of them may not have clinical backgrounds.

• Have someone with no knowledge of the case review the file before it is sent out to look for obvious errors or missing materials.

• Research other local coverage determinations (LCDs) to document if they support your case.

For reference

Related Academy resources