Healthcare Audit Appeal and Defense

Our Medicare Appeal Process

We can build a strong strategy to help navigate the appeal process. A typical Medicare Part B Appeal process breaks down as follows.

Step One: Redetermination With a Medicare Administrative Contractor (MAC)

You must file a redetermination request within 120 days from the date you got the Electronic Remittance Advice (ERA) or Standard Paper Remittance (SPR) Advice listing the initial determination. The receipt date is presumed to be five days after the notice date unless there’s evidence you didn’t get it within that time.

MACs generally issue a decision within 60 days of the date they get the redetermination request. Your MAC tells you its decision with an MRN, or you get a revised ERA or SPR if they reverse the initial decision and pay the claim in full.

Step Two: Reconsideration With a Qualified Independent Contractor (QIC)

You must file a reconsideration request within 180 days from the date you got the MRN. Make QIC review requests for a MAC dismissal within 60 days of getting the dismissal notice. The receipt date is presumed to be five days after the notice date unless there’s evidence you didn’t get it within that time.

A QIC generally sends a decision to all parties within 60 days of the date they get the reconsideration request. If the QIC can’t complete its decision in the applicable time frame, it informs you of your rights and the procedures to escalate the case to OMHA. If you don’t get a reconsideration decision within 60 days, consider allowing an extra five to 10 days for mail delays before escalating your appeal to OMHA.

Step Three: Decision From the Office of Medicare Hearing and Appeals (OMHA)

You must file an ALJ hearing request within 60 days from the date you got the reconsideration decision letter or QIC dismissal notice. If requesting escalation to OMHA, file a request with the QIC for OMHA review after the reconsideration period expires. The receipt date is presumed to be five days after the notice date unless there’s evidence you didn’t get it within that time.

OMHA has 90 days to complete its review and issue a decision. Although the large appeal request volume previously caused processing delays, OMHA is on track to return to a 90-day adjudication period. OMHA generally processes ALJ hearing requests in the order they arrive and as quickly as possible, given pending requests and adjudicatory resources. OMHA prioritizes expedited Part D prescription drug denial cases and appeals initiated by a Medicare beneficiary or enrollee. If OMHA doesn’t issue a decision within the applicable time frame, you may ask OMHA to escalate the case to the Council.

Step Four: Medicare Appeals Council Review

You must file a Council review request within 60 days from the date you got the OMHA decision or dismissal. The receipt date is presumed to be five days after the notice date unless there’s evidence you didn’t get it within that time.

The Council generally decides within 90 days of the date they get the OMHA decision or dismissal review request. If the Council review comes from an escalated appeal, the Council has 180 days from the date they get the escalation request to issue a decision. A decision may take longer for many reasons. If the Council doesn’t issue a decision within the applicable time frame, you may ask the Council to escalate the case to the U.S. District Court. If you request U.S. District Court escalation, you must send a copy of the request to all other parties and the Council.

Step Five: U.S. District Court Judicial Review

You must file a judicial review request within 60 days from the date you got the Council decision or after the Council decision time frame expires.

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Sean M. Weiss, CHC, CEMA, CMCO, CPMA, CPC-P, CPC, CMOM, CMC, CMIS

Compliance

Jesse D. Overbay, J.D.

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Build a Strong Healthcare Audit Defense Strategy

At the root of any audit defense is a strong strategy. Here are some tips that can bolster your healthcare audit defense:

Engage counsel and a subject matter expert

To best handle an audit, you must have counsel for the legal process as well as guidance for the technical rules and guidelines the payer is utilizing to request the demand. Having both engaged within five to seven days of the original demand gives them time to adequately work on your behalf.

Review, revise, and keep your compliance plan up to date

Ever heard the term “The best defense is a good offense?” Well, this is very true in compliance. If you have a “living” compliance plan, you put yourself in a great position for any negotiation or litigation with a payor. To have a living compliance plan, at a minimum, you need annual payor updates, open knowledge throughout your organization of whom the compliance officer is, and an understanding of how they can confidentially bring up compliance concerns.

Understand your rights and the appeal process

There is always an option to challenge negative audit results against your practice. These outcomes can depend on the auditing party and overall circumstances, but ensure you and your counsel know those steps and the key factors in each step.

Importance of Partnering With a Healthcare Audit Defense Lawyer

A winning strategy begins with a winning team — collaboration between the client and our team is crucial. You must have a sound strategy with experienced professionals who thoroughly understand the appeal process for all payors. DoctorsManagement provides access to experts in auditing, compliance (regulations) coding and documentation, audit appeal, medical necessity, and statistical and post-audit extrapolation. We can:

Help healthcare providers from recoupments based on auto-denials, auto-down coding of claims, and over-aggressive and often flawed audit findings
Offer regulatory compliance professionals, dual-certified auditors and coders, economists, statisticians, data analysis, and clinical documentation experts to integrate into your defense team seamlessly
Engage as an expert witness part of your defense team

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Proven History

We have a proven history of successful audit appeals. On an annual basis, our team of experts eliminates over $100 million in improper provider repayment demands, including administrative, civil, and criminal proceedings. Some highlights include:

7 count indictment reduced to 1 count of a class A misdemeanor
22 count indictment — client found innocent on the 11 counts our experts testified on
$11 million Medicare refund demand was reduced to $3,000, and payment suspension lifted
$14 million Medicare refund demand was reduced to $233
Provider serviced with 125-year license suspension resulted in the case being dismissed and the provider reinstated

Hire Us as Your Healthcare Audit Defense Lawyers

Understanding what drives a level of service, what is required to support medical necessity, and how to defend clinical judgment is critical to the defensibility of your claims.

Our healthcare audit defense lawyers have extensive experience working with the Office of Inspector General (OIG), the Department of Justice (DOJ), the U.S. Attorney’s Office, the Centers for Medicare and Medicaid Services (CMS), and commercial payers at the highest levels.

We’ve worked incredibly hard to ensure that we build rock-solid defense strategies against unsubstantiated medical audits and have a proven history of successful audits. Contact us for a free consultation.

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