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Linda Collins Blogger

Time is Money…

Posted by Linda Collins | December 10, 2012

​There has been much discussion about the RAC audits and how to provide the documentation needed to beat the audit. If you practice does receive an Overpayment Demand Letter there are specific steps and timeframes to follow to protect your practice and your money.

First-Level Appeal: You have 120 days to file the first appeal which is known as a "redetermination." Redeterminations are conducted by Medicare Administrative Contractors (MAC). Here’s where it gets tricky. While you have 2 months to file that first appeal, you can only avoid a Medicare recoupment action if you do so within 30 days. The request for redetermination must be date stamped and in the MAC's mailroom no more than 30 days from the date of the demand letter.

Second-Level Appeal: If you lose your first-level appeal and decide to appeal that adverse decision, you must file your second-level appeal within 60 days of receipt of the first level determination to extend the prohibition on recoupment. Second-level appeals are called "reconsiderations." Reconsiderations are conducted by Qualified Independent Contractors (QICs). (If you lose your second-level appeal, recoupment will commence 30 days after the second-level appeal decision is issued. Medicare will recoup the full amount of the audit determination plus interest. This money will not be returned to you unless you prevail in one of the next levels of appeal)

Third-Level Appeal: You have 60 days from receipt of the second level reconsideration to appeal to the third level, at which an Administrative Law Judge (ALJ) will review your case. If the ALJ level process reverses the Medicare overpayment determination, Medicare will refund both principal and interest collected, and pay interest on any recouped funds that Medicare took from ongoing Medicare payments. We are hearing that in some sections of the country, waits for ALJ hearings are 12 months or more.

Fourth-Level Appeal: You have 60 days to appeal to the fourth level. At the fourth level of appeal, an HHS Department Appeals Board (Medicare Appeals Council) will review your case. The MAC will generally issue its decision within 90 days from receipt of your request for review.

Fifth-Level Appeal: Again, you have 60 days to appeal to the fifth level. Here, a Federal District Court will review your case. At least $1,220 must be in controversy following the MAC review, and the government increases this “minimum amount in controversy” annually.

Having all the documentation in the patient’s file prior to delivery of service makes it easy to meet the deadlines for appeals. This means you can keep control of your money during the sometimes lengthy appeal process. And since the majority of appeals are in the provider’s favor at the ALJ level, this means you may never have to pay back money or wait for your money to be returned. Take the time to manage your documentation up front because, in this case, time is money.

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