The Audit Appeals Process

The Medicare Appeals Process is the same regardless of whether the initial determination comes from the RACs, ZPICs, MACs or other contractor. Our firm regularly helps providers navigate through all stages of this appeals process which consists of the following steps:

1. Redetermination. The first level in the appeals process is redetermination. A request for redetermination must be filed in writing within 120 calendar days of receiving notice of an initial determination, which may come by way of a written demand letter or electronic notification via a remittance advice. There is no amount in controversy requirement.

   Note: Although providers have 120 days to submit their redetermination request, the contractor can begin recouping any alleged overpayment while the appeal is pending unless the redetermination is requested within 30 days from the date of the demand letter. If an appeal is not received by the CMS contractor within 30 days, recoupment can begin on day 41 and any amount recouped is retained until final determination.

2. Reconsideration. The second level in the appeals process is called Reconsideration and is conducted by a Qualified Independent Contractor (QIC). This second level of appeal must be filed within 180 calendar days of receiving notice of the redetermination decision. There also is no amount in controversy requirement for this stage of appeal.

   Note: As with the redetermination level of appeal discussed above, the reconsideration level of appeal has a separate deadline that must be met in order to avoid recoupment of alleged overpayments by the CMS contractors. Specifically, recoupment can be stopped if the request is received by the CMS contractor within 60 days following the date of redetermination. If the request for reconsideration is not received by the CMS contractor within 60 days of the redetermination decision, recoupment can begin on day 76. It is also important to note that providers must present all evidence at the reconsideration level of appeal. If information is not submitted prior to the issuance of the Reconsideration decision, the provider will be precluded from presenting any additional evidence at the later stages of appeal unless the provider can demonstrate that it had “good cause” for failing to submit the information at the Reconsideration level.

3. Administrative Law Judge (ALJ). The third level of appeal is a hearing before an Administrative Law Judge (ALJ), which is most often conducted via telephone, although the hearing can be conducted via video conference or in person. Treating providers, attorneys and expert witnesses often participate in these hearings on behalf of providers. The request for an ALJ hearing must be filed within 60 days following receipt of the QIC’s reconsideration decision. This request must meet an amount in controversy requirement which changes yearly. Multiple claims can be aggregated to meet this amount.

4. Medicare Appeals Council (MAC). The fourth level of appeal is the Medicare Appeals Council (MAC) Review. The MAC is within the Department Appeals Board of the U.S. Department of Health and Human Services. A request for MAC Review must be filed within 60 days following receipt of the ALJ’s decision and must meet an amount in controversy requirement which changes yearly. The requesting party must explain its disagreement with the ALJ (e.g., was the ALJ decision inconsistent with statutes, regulations, CMS rulings or other authority?). MAC decisions are generally “on the record” meaning there is no hearing. However, a party can request oral argument (which will be granted if the MAC determines that the appeal raises an important question of law, policy or fact that cannot readily be decided on written submissions alone).

5. Federal District Court. The final step in the Medicare appeals process is review in Federal District Court. An appeal to Federal District Court must be filed within 60 days from the receipt of the MAC’s decision, and must meet an amount in controversy requirement which changes yearly.

Regardless of the CMS Medicaid contractor performing the review (e.g., MICs or Medicaid RACs), the Medicaid appeals process is governed by the statutes, regulations or administrative rules of the state. The process varies from state to state. In most states, the Medicaid appeals process includes the opportunity for a hearing in front of an administrative tribunal such as an administrative law judge. There may also be opportunities for informal resolution or settlement.