In any event, when you feel that your Medicare claim has been unjustly rejected, then you need to appeal the decision.  Not only for the benefit of your patient, but if you show the Medicare administrators that you are willing to fight to get what is legally your just payment, then you may see less indiscriminate Medicare claim rejections in the future.  But, being a good government program, there are specific appeal processes and forms which must be used in the appeals process.

 There are five levels of the appeals process for the denial of Medicare Part B claims.  The five levels are:

 Redetermination – Which is performed by the carrier/insurer (Blue Cross/Blue shield for example)

Reconsideration – Which is performed by a Qualified Independent Contractor

 Hearing – Before an Administrative Law Judge

 Review – Performed by the Medicare Appeals Council (No conflict of interest there)

 Judicial Review – Heard within a US District Court

 If you are Medicare participating provider then you can appeal the rejection of your claim directly.  If you are not a participating provider, then your appeal rights are limited.  However, the Medicare beneficiary (your patient) can assign their right to appeal to a non-participating provider through form CM-20031, which must be signed by the beneficiary and the provider.

 You can begin the appeals process by filing a form CMS-20027 (or the Medicare contractor’s specific form) within 120 days of the initial denial of the claim.  If you have any additional documentation supporting the initial claim, submit this documentation with the request for redetermination.  The appeal is supposed to be reviewed by different personnel than the original claim, and must be determined within 60 days.

If you are dissatisfied with the outcome of the redetermination, then the next step is to request a reconsideration from a Qualified Independent Contractor (QIC).  Within 180 days or receiving the denial of your claim from the redetermination you can file form CMS-20033 (or the Medicare contractor’s specific form) requesting a reconsideration.  Clearly outline why you disagree with the redetermination.  Any additional information that you have to support your position should be included with the request for reconsideration.  Any additional information, not submitted with the request for redetermination, may not be allowed at the reconsideration, so make sure any pertinent documentation was submitted at the request for redetermination.  The QIC should reach its decision within 60 days, and send its conclusion to all parties involved.  The decision should contain information on further appeals options if the decision is not fully favorable to the claimant.                                                                                                      

If your claim is still denied, then you have a decision to make.  Up to this point there has been little money involved, other than time for you office staff or billing contractor.  To further appeal the decision on your claim, the next step is to appeal the decision to a hearing before an Administrative Law Judge.  This may involve hiring a lawyer, and spending time in a court room.  If you strongly believe that your claim has been unjustly denied, then you may want incur the expense to support your right to get paid.

  My experience, and the experience of my colleagues, has been that it is usually not worth the expense to continue to push the issue beyond the request for reconsideration. This decision may have to be made on an economic basis, rather than on principle.  But, that’s your call.

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3 Comments
#1 by MARCIE GARCIA on February 17th, 2011

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I’ve had Medicare deny claims because after my Doc transfered a patient from HealthSouth Rehab Hospital to Scottsdale HealthCare Shea for ie. pt went into respiratory failure. Because both hospitals are POS 21 and an Internist saw the patient on the same date of service whichever Doc gets the claim in FIRST gets paid and Mdcr denies the Second Doc’s Charges. Medicare told me “WE DO NOT LOOK AT THE NAME OF THE FACILITY ONLY THE POC CODE.” “WE CAN’T LOOK AT EVERY BOX TO SEE THAT THE POS IS A DIFFERENT FACILITY” Our office has never had this problem until this year. Mdcr blames this (and every other problem) on the fact that the “consults codes were deleted”. A consult code would NOT have been used in the above situation. The fact was the patient was being transfered from one “acute” care hospital to a different “acute care” hospital and seen by 2 DIFFERENT DOCTORS. I finally found “MODIFIER 77″ and got the claims paid.
#2 by Dr. Kohansieh on February 18th, 2011

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Thanks a lot for the great info (how to appeal medicare denial of the medical bills). Please email me similar information in the future. I am a chiropractor but it seems the info you provided can apply to any health care provider.

All the best.
Dr. K
#3 by ronald g oconnor DC on February 23rd, 2011

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DR. Kohansieh
I am also a chiro. I went through an randomly selected audit, it is not a fun experience. All for naught because, as non-participating, I didn’t know that the patient has to ask for the re-determination. The nurse who rejected my records as not med necessary didn’t tell me this. In writing, she misled me.
All providers need to know this. My staff spent many hours talking to medicare about where our re-deter paperwork went ( we mailed it certified mail); we re submitted twice , it got in lost the the black hole that is medicare. We sent two certified letters to the re-determ address, no response. By the way, they have no phone number, you can’t call them. I finally got on the phone myself after my two staff refuse to talk to medicare anymore. Three days, total 5-6 hrs, talked to numerous “experts” at medicare who each gave a different take on the rules.
I even got my US congressman’s office in on it, they sent a letter to CMS, no answer to my specific questions or about the proper procedure, or where my records and re-determ responses were on 50 (!!!!!!) patients!!
Finally, a medicare person told me the patient must ask for the re-determ. By this time, the limit for second level has expired.
I wrote back, documenting their mis-info to me, answer; time has expired.
My advice to providers is to not take assignment. If you do they can demand all their money back. I know of Drs who were asked for 400 k back!!
The only bright side to this is I didn’t take assingment, which is what our state chiro assoc has always advocated.
The bottom line is that these reviewers are making their job by cutting your claims. You are literally paying their salary with your hard work and your desire to take care of your patients!
The system is totally corrupted. Don’t take assignment, have the patient sigh the ABN DISCLOSURE that makes them aware that medicare probably will not pay for your services and if they don’t the patient will be responsible. This has worked out great for us. Good luck to all.
R. OConnor DC