Medicare Appeals: Rules and Regulations
Sara Beck
Description
Collection
Title:
Medicare Appeals: Rules and Regulations
Creator:
Sara Beck
Date:
5/22/2013
Text:
Hey List,
I wanted to update everyone on some of the rules and
regulations outlined within the Social Security Act (the Act that governs and
regulates the appeals process). One of
the most unknown rules is that an ALJ has 90 days to set a hearing and issue a
decision. Providers are now waiting over
a year in order to even receive a hearing date. Of course, I can empathize with
the Judge’s because they receive thousands of hearing requests daily. However, our profession has also been
extraordinarily hit hard with excessive audits and a copious amount of overpayment
requests all at once; some of us even receive 20-30 audits within a few days
for a small business. And ALJ’s get paid for this, we do not; in fact, we are losing
money. Yet, we are STRICTLY held to the time limitations outlined in the Social
Security Act. I think ALL parties (Medicare, contractors and ALJ’s) should also
be strictly held to the same rules that they enforce upon us.
I have included some of the rules within the Social Security
Act that pertain to Medicare, their contractors (QIC’s) and ALJ’s concerning
appeals for overpayments:
Limitation on
Recoupment Section 1893 (f)(2)(a) of the Social Security Act:
When a
valid first level appeal request or a second level appeal request is received from
a provider on an overpayment, recoupment efforts WILL cease.
If the
Administrative Law Judge process reverses the Medicare overpayment decision,
previously collected principal and interest will be refunded.
-Will also pay interest on any
recouped funds that Medicare took from ongoing Medicare payments.
(Medicare CANNOT
recoup funds on an appeal while it is within the first two levels)
§1395ff Determinations; appeals (42 U.S.C.A. §1395ff)
Redeterminations:
Medicare must make a determination within 60 days of receipt. The determination must include: (1) written
notice (2) reasons for the determination (3) summary of clinical or scientific
evidence used in making the redetermination
Reconsideration: Contractor must issue a decision not later
than the end of the 60 day period beginning on the date a request for
reconsideration is timely filed.
(H) Ensuring
consistency in decisions: Each qualified independent contractor shall monitor
its decisions with respect to reconsiderations to ensure the CONSISTENCY of
such decisions.
(QIC’s are
REQUIRED to produce consistent results)
Administrative
Law Judge Hearing: an administrative law judge shall conduct and conclude a
hearing on a decision of a qualified independent contractor and render a
decision on such hearing by not later than the end of the 90 DAY PERIOD
beginning on the date a request for hearing has been timely filed.
Please contact me
with any questions. Hope this helps,
Sara Beck
San Joaquin O
& P
I wanted to update everyone on some of the rules and
regulations outlined within the Social Security Act (the Act that governs and
regulates the appeals process). One of
the most unknown rules is that an ALJ has 90 days to set a hearing and issue a
decision. Providers are now waiting over
a year in order to even receive a hearing date. Of course, I can empathize with
the Judge’s because they receive thousands of hearing requests daily. However, our profession has also been
extraordinarily hit hard with excessive audits and a copious amount of overpayment
requests all at once; some of us even receive 20-30 audits within a few days
for a small business. And ALJ’s get paid for this, we do not; in fact, we are losing
money. Yet, we are STRICTLY held to the time limitations outlined in the Social
Security Act. I think ALL parties (Medicare, contractors and ALJ’s) should also
be strictly held to the same rules that they enforce upon us.
I have included some of the rules within the Social Security
Act that pertain to Medicare, their contractors (QIC’s) and ALJ’s concerning
appeals for overpayments:
Limitation on
Recoupment Section 1893 (f)(2)(a) of the Social Security Act:
When a
valid first level appeal request or a second level appeal request is received from
a provider on an overpayment, recoupment efforts WILL cease.
If the
Administrative Law Judge process reverses the Medicare overpayment decision,
previously collected principal and interest will be refunded.
-Will also pay interest on any
recouped funds that Medicare took from ongoing Medicare payments.
(Medicare CANNOT
recoup funds on an appeal while it is within the first two levels)
§1395ff Determinations; appeals (42 U.S.C.A. §1395ff)
Redeterminations:
Medicare must make a determination within 60 days of receipt. The determination must include: (1) written
notice (2) reasons for the determination (3) summary of clinical or scientific
evidence used in making the redetermination
Reconsideration: Contractor must issue a decision not later
than the end of the 60 day period beginning on the date a request for
reconsideration is timely filed.
(H) Ensuring
consistency in decisions: Each qualified independent contractor shall monitor
its decisions with respect to reconsiderations to ensure the CONSISTENCY of
such decisions.
(QIC’s are
REQUIRED to produce consistent results)
Administrative
Law Judge Hearing: an administrative law judge shall conduct and conclude a
hearing on a decision of a qualified independent contractor and render a
decision on such hearing by not later than the end of the 90 DAY PERIOD
beginning on the date a request for hearing has been timely filed.
Please contact me
with any questions. Hope this helps,
Sara Beck
San Joaquin O
& P
Citation
Sara Beck, “Medicare Appeals: Rules and Regulations,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 5, 2024, https://library.drfop.org/items/show/235131.
