The Five Levels of Medicare Review for Health Care Providers
When a Medicare Administrative Contractor (MAC) or other CMS contractor/agency audits your practice’s invoices, you will receive a document called a Remittance Advice (RA), containing the MAC’s initial determination.
If that determination is against your interest, there is a five-level appeals process in place for challenging the decision. This process is cumbersome, but we’ll lay out its basic rules and procedures below.
Level 1: Redetermination by a MAC
A MAC is a private, third-party organization contracted by the federal government to assist CMS in auditing invoices and handling claims, including appeals.
As a health care provider, your first avenue for appeal is a new MAC review of the initial adverse determination.
How to File a Medicare Appeal for MAC Redetermination
Your RA will include information about how to file an appeal. This can typically be done online, by mail, or in person, depending on designated MAC.
You should submit a formal Medicare Redetermination Request (Form CMS-20027), or you might choose to submit a written letter instead, so long as it complies with the directions in your RA. Either way, the request must be signed. Include any relevant documents as attachments, but only send copies. Keep the originals.
Your Medicare appeals attorney can handle this process for you.
How Long Do You Have?
120 days from receipt of the RA
Minimum Amount in Controversy (AIC) Requirement
None
(As outlined below, some levels of Medicare appeal have an Amount in Controversy requirement. This means the dollar amount in dispute must reach a certain threshold to be eligible for that level of review.)
Who Decides?
MAC staff members who were not involved in the original determination. Nevertheless, the MAC has a built-in profit incentive to decide against you.
How Long Does This Level of Medicare Appeal Take?
You will typically receive a Medicare Redetermination Notice (MRN) or revised RA within 60 days of filing the request for redetermination.
Level 2: Reconsideration by a Qualified Independent Contractor (QIC)
How to File a Medicare Appeal for Reconsideration
Your MRN or revised RA will contain even more specific instructions about where and how to file for reconsideration by a QIC. You may use Form CMS-20033 or your own compliant written instrument.
It’s important to be extremely thorough and persuasive when preparing this request, and we strongly urge you to work with a Medicare appeals attorney who has experience in representing health care providers.
How Long Do You Have?
180 days from receipt of the MRN or revised RA
Minimum Amount in Controversy (AIC) Requirement
None
Who Decides?
The QIC is typically a panel, which might include physicians and other health care professionals.
How Long Does This Level of Medicare Appeal Take?
Decisions come within 60 days unless you’re otherwise notified.
Level 3: Administrative Law Judge (ALJ) Hearing
How to File a Medicare Appeal for an ALJ Hearing
The specific procedure for filing appeal will depend on the directions in your letter from the QIC, the timeframe in which you are filing, whether you are requesting a telephone/video or in-person hearing, how many parties are involved, and other factors.
Here again, we strongly urge you to consult with a Medicare appeals lawyer when preparing an appeal at the ALJ hearing level.
How Long Do You Have?
60 days from receipt of the QIC reconsideration decision letter
If the reconsideration period has expired, you can file a request for a review by the Office of Medicare Hearings and Appeals (OMHA) instead.
Minimum Amount in Controversy (AIC) Requirement
$160 as of 2017 (readjusted annually)
Who Decides?
An Administrative Law Judge, who works for the federal government but is independent from CMS. (In OMHA reviews, either an ALJ or an attorney adjudicator will decide; the OMHA is also independent of CMS.)
How Long Does This Level of Medicare Appeal Take?
Filing for Medicare appeal at this level can entail a long wait. The timeline will depend on the nature of your case and when it gets assigned to an ALJ / OMHA.
Level 4: Review by the Medicare Appeals Council
Note: The Medicare Appeals Council is not to be confused with the aforementioned Medicare Administrative Contractors (MACs).
How to File a Request with the Medicare Appeals Council
Send a detailed request that conforms with the instructions you received at the end of your ALJ hearing. You may use Form DAB-101. Detail and compliance are extremely important. Again, it would be unwise to proceed without a Medicare appeals attorney representing your interests.
How Long Do You Have?
You have 60 days from receipt of the ALJ decision (or 60 days from expiration of the OMHA decision timeframe), within which to file.
Minimum Amount in Controversy (AIC) Requirement
None
Who Decides?
The Medicare Appeals Council itself
How Long Does This Level of Medicare Appeal Take?
In most cases, a decision will come within 90 days.
Level 5: Judicial Review in U.S. District Court
How to File a Medicare Appeal in Federal District Court
You are now moving into a formal court proceeding and should absolutely be represented by an attorney if you have not been already. The Council will give you detailed appeals instructions.
How Long Do You Have?
60 days from receipt of the Council’s decision (or after the Council’s decision window expires)
Minimum Amount in Controversy (AIC) Requirement
$1560 as of 2017 (readjusted annually)
Who Decides?
The U.S. District Court. You will proceed on the court’s schedule.
Criminal Statutes to Familiarize Yourself With
Most Medicare appeals are civil in nature. However, these matters can also lead to criminal investigations and health care fraud charges. Therefore, if you’re facing a civil audit or appeal, it’s important to be familiar with the most relevant criminal statutes as well:
- 18 U.S. Code 1347: the health care fraud statute
- 18 U.S. Code 1349: attempted health care fraud / conspiracy to commit health care fraud
- 18 U.S. Code 1341: the mail fraud statute
- 18 U.S. Code 1343: the wire fraud statute
If you are facing criminal conviction, an experienced Medicare appeals attorney can help you fight the charges (and pursue appeals) in federal criminal court.
Talk to the Medicare Appeals Lawyers at The Criminal Defense Firm
The Criminal Defense Firm is a national law firm where former federal prosecutors now fight for the rights of health care providers. Our firm has spent many years focusing on high-stakes legal matters in the medical field, including health care fraud cases and Medicare appeals.
We have an outstanding track record of success, and we are committed to fighting for the absolute best outcome for our clients.
We offer free and confidential consultations. To speak with one of our Medicare appeals attorneys, please contact us online or call 866-603-4540 right away.
National Reach CMS Appeals Lawyers. Primary Office in Dallas, TX.
Brian Kuester offers his extensive experience to counsel companies and individuals under civil or criminal government investigation. When resolution requires litigation, clients choose Mr. Kuester’s proven court and litigation experience.