New Medicare Appeals Rules

New Medicare Appeals Rules

Article Jun 30, 2005

Recently, there was an announcement of a drastic change in the way all medical service providers will appeal denied Medicare claims. On March 8, 2005, the Department of Health and Human Services (DHHS) and the Center for Medicare and Medicaid Services (CMS) published an Interim Final Rule in the Federal Register, titled “Changes to the Medicare Claims Appeal Procedures,” regarding the Medicare program. Some of the provisions contained in this Rule come from the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA).

The Rule, as published, is 80 pages long and contains many changes, both large and small, to the Medicare appeals rules. The major changes are to the structure of the appeals process, including the following: Under the new Rule, there will be a uniform appeals process for all Part A and B claims; no longer will the appeals process vary between carriers. As part of this new process, a new position will be created for a qualified independent contractor (QIC), to conduct reconsiderations of claim denials made by fiscal intermediaries, carriers and quality improvement organizations. There will only be four of these QICs nationwide. There will also be a QIC appeals panel made up of medical professionals, which will reconsider cases involving medical necessity issues. The time frame for making decisions on administrative appeals has also dramatically decreased; a process which could previously take more than three years must now be completed in no more than 300 days. And finally, if the carrier or fiscal intermediary denies your claim, and that denial is upheld by the QIC or QIC appeals panel, you can still appeal the denial to an Administrative Law Judge (ALJ); however, the ALJ will no longer be a Social Security ALJ, but an DHHS ALJ, whose sole responsibility will be Medicare appeals.

There are also many other, less noticeable changes. However, even some of these smaller details may greatly affect how appeals are filed and handled by medical service providers, such as ambulance services. One such change is that you must present all evidence (medical records, etc.) that supports your appeal at or beneath the QIC hearing level. You will no longer generally be able to bring in new evidence at the ALJ level. This and other changes will force medical professionals to be very thorough when filing appeals for their denied claims.

There is good news and bad news between the lines of this new Rule. The good news includes the reduction in time that it takes for an appeal to be decided. In an industry where receipt of Medicare payments is often necessary to keep operations up and running, a shortened appeals process will be a welcome change. However, the bad news is that there are new hoops that you must jump through to make sure you win your appeal. This may lead to many services not appealing claims, or not properly appealing claims, and thereby losing money they are owed. Finally, there are provisions of the new Rule that are difficult to categorize as good or bad, such as creation of the new DHHS dedicated ALJs. This could be a good thing for medical providers, in that ALJs will now be more familiar with Medicare policy; however, Medicare may now be more aggressive in arguing its side of these appeals.

Discussing the issue of Medicare appeals gives me the opportunity to raise a side issue: Just because an ambulance claim is denied does not mean that it should not have been paid. Ambulance claims constitute a relatively small portion of all Medicare claims, and therefore the ambulance industry is not top priority when it comes to training the Medicare carrier’s employees. Also, ambulance claims do not use the same coding procedure as virtually every other healthcare industry does. These things often lead to improperly denied claims for ambulance service. By following the proper appeal procedures and making the appropriate medical or legal/coverage arguments, often-denied ambulance claims can be recovered. Of the claims that I handle on appeal on behalf of ambulance service clients, the vast majority are successful. The new rules will make the appeals process a little more difficult to navigate, but don’t let that discourage you from seeking payment for claims you feel were appropriate.

The published Rule is an “interim” final rule and was effective as of May 1, 2005; CMS accepted comments on the Rule until May 9, 2005. Therefore, in the next few months, there should be an additional publication in the Federal Register that will address some of the comments and questions, as well as any changes that CMS deems appropriate. Even though the Rule is currently effective, it will take a while to get it implemented. The target date for implementation for Part A claims was May 1, 2005, and for Part B claims it is January 2006.

To read the entire Federal Register publication, go to:

Nothing in this article should be construed as legal advice. For specific, up-to-date legal advice about the laws mentioned in this article or about your state’s laws, consult an attorney.

State troopers rendered aid before turning them over to responding EMS units and New Castle County Paramedics.
Three people were fatally shot and at least 21 others were wounded in separate attacks from Saturday morning to early Sunday.
Crestline Coach attended the Eighth Annual Saskatchewan Health & Safety Leadership conference on June 8 to publicly sign the “Mission: Zero” charter on behalf of the organization, its employees and their families.
ImageTrend, Inc. announced the winners of the 2017 Hooley Awards, which recognize those who are serving in a new or innovative way to meet the needs of their organization, including developing programs or solutions to benefit providers, administrators, or the community.
Firefighters trained with the local hospital in a drill involving a chemical spill, practicing a decontamination process and setting up a mass casualty tent for patient treatment.
Many oppose officials nationwide who propose limiting Narcan treatment on patients who overdose multiple times to save city dollars, saying it's their job to save lives, not to play God.
While it's unclear what exact substance they were exposed to while treating a patient for cardiac arrest, two paramedics, an EMT and a fire chief were observed at a hospital after experiencing high blood pressure, rapid heartbeat, and mood changes.
After a forest fire broke out, students, residents and nursing home residents were evacuated and treated for light smoke inhalation before police started allowing people to return to their buildings.
AAA’s Stars of Life program celebrates the contributions of ambulance professionals who have gone above and beyond the call of duty in service to their communities or the EMS profession.
Forthcoming events across the country will provide a forum for questions and ideas
The Harris County Office of Homeland Security & Emergency Management (HCOHSEM) has released its 2016 Annual Report summarizing HCOHSEM’s challenges, operations and key accomplishments during the past year.
Patients living in rural areas can wait up to 30 minutes on average for EMS to arrive, whereas suburban or urban residents will wait up to an average of seven minutes.
Tony Spadaro immediately started performing CPR on his wife, Donna, when she went into cardiac arrest, contributing to her survival coupled with the quick response of the local EMS team, who administered an AED shock to restore her heartbeat.
Sunstar Paramedics’ clinical services department and employee Stephen Glatstein received statewide awards.