In an effort to ensure or improve the quality of decisions by Medicare Administrative Contractor (MAC) staff concerning claims adjudication and denials, the Centers for Medicare and Medicaid Services (CMS) has issued a program transmittal that requires MACs to support their decisions through the third level of the appeal process. Transmittal R543PI (change request 8501) requires MACs to assign a physician to participate or take party status at administrative law judge (ALJ) hearings to oversee the hearings. The transmittal takes effect Oct. 27, 2014. These changes cover decisions made by other Medicare audit contractors, but the MAC is responsible for overseeing the ALJ hearings. The transmittal also instructs MACs to make sure they are included in the notices of upcoming hearings and to select those hearings to attend and whether they should participate as a party or a participant. There are important differences in what they can do depending on their participation status. MAC Oversight of ALJ Hearings Likely to Further Erode Provider Mistrust For many providers, the ALJ hearing is the first opportunity they have for a fair and impartial adjudication of their appeals of claims denials. The first two levels of appeal are already controlled by CMS and […]
In an effort to ensure or improve the quality of decisions by Medicare Administrative Contractor (MAC) staff concerning claims adjudication and denials, the Centers for Medicare and Medicaid Services (CMS) has issued a program transmittal that requires MACs to support their decisions through the third level of the appeal process.
Transmittal R543PI (change request 8501) requires MACs to assign a physician to participate or take party status at administrative law judge (ALJ) hearings to oversee the hearings. The transmittal takes effect Oct. 27, 2014.
These changes cover decisions made by other Medicare audit contractors, but the MAC is responsible for overseeing the ALJ hearings.
The transmittal also instructs MACs to make sure they are included in the notices of upcoming hearings and to select those hearings to attend and whether they should participate as a party or a participant. There are important differences in what they can do depending on their participation status.
MAC Oversight of ALJ Hearings Likely to Further Erode Provider Mistrust
For many providers, the ALJ hearing is the first opportunity they have for a fair and impartial adjudication of their appeals of claims denials. The first two levels of appeal are already controlled by CMS and its contractors, and providers often are dissatisfied with the result. As with many decisions such as this, there are likely to be unintended consequences for all parties involved.
One outcome that is certain is that both providers and MACs are going to have to make a better case to support their appeal request to overturn a denial or to uphold a denial decision. The most successful appellants or contractors will be those who do a better job of gathering information to support their assertions and the laws or regulations that underpin them. Also, those that understand the process best will be successful more often than those who do not.
It is also likely that legal counsel will get involved more frequently in the appeal process, especially when the amount of money involved is large. This will add cost to the process for all parties involved.
Another potential consequence is a change in the dynamics of the ALJ hearings, which are likely to become more adversarial.
Takeaway: Providers who enter into the appeal process are going to need to be better prepared to make a good medical and legal case to support their assertions that Medicare should cover and pay for the services in question.
