Moving the HME Industry Forward

Billing/Reimbursement

Understanding the Administrative Appeals Process – Part Two of Four

August 26, 2013

AMARILLO, TX – Post-payment audits (by DME MACs, ZPICs, and RACs) are a permanent part of the DME industry.  Regardless of how thorough the DME supplier’s patient files are, the chances of winning at the audit stage are small.  This is because the auditor is looking for a reason to deny a claim and demand a repayment.  As a result, if subjected to an audit, the DME supplier can expect to traverse the various administrative appeal stages.

This is Part Two of a four part series on the administrative appeals process.  Part One addressed the redetermination level of appeal.  Part Two addresses the reconsideration level of appeal.  Part Three addresses the administrative law judge level of appeal.  Part Four addresses the Medicare Appeals Counsel/judicial review levels of appeal.

Part Two – Reconsideration – Second Level of Appeal
If a supplier disagrees with the redetermination decision, it has 180 days from the date the supplier received the redetermination decision to file a request for reconsideration.  The QIC reconsideration consists of an independent review.  Like the redetermination review, a reconsideration review is based solely on the written record.  QICs must follow national coverage determinations, CMS rulings, and applicable laws and regulations.

The request for reconsideration must be received by the QIC within the 180-day period.  If the request is even one day late, it will not be considered and the overpayment demand will stand.  To stay recoupment, a request for reconsideration should be filed within 60 days of the date of the redetermination decision.

The request for reconsideration must be in writing and filed with the QIC.  The request may be on a standard CMS form (CMS-20033), the form included with the redetermination decision, or another writing (e.g., a letter).  If the request is made in a letter, the letter must contain all of the following:
• beneficiary’s name;
• beneficiary’s Medicare health insurance claim number;
the specific service and item and date of service for which reconsideration is requested;
• the name and signature of the party making the request or the party’s representative; and
• the name of the contractor who made the redetermination.

Also, the supplier should explain why it disagrees with the initial determination and redetermination and present any additional evidence and arguments of fact or law.

When the QIC receives a request for reconsideration, it will request the case file from the DME MAC.  It is very important to know that evidence not submitted to the QIC will not be considered at an ALJ hearing or further appeal unless good cause is shown as to why the evidence was not previously provided.  Therefore, all relevant information proving the supplier’s case should be submitted to the QIC.  Every level of review is what is considered a de novo review, meaning it is a new and independent review of the claim.  So, even if a specific requirement was not questioned at a lower level, you should provide all information that supports the medical necessity of the claim.  You never know what will catch the eye of the reviewer.

Within 60 days of receiving a request for reconsideration, the QIC must:
• issue a written decision; or
• provide the supplier with a statement advising that it is unable to complete its review within the 60-day time frame and provide reasons why it could not complete the review during that time frame in accordance with the rule.

If a supplier files a timely request for reconsideration to the QIC and the QIC has not made a decision within the 60-day period, then the supplier may send a written request to the QIC to escalate the appeal to the ALJ.  Within five days of receiving a request for escalation, the QIC must either issue the reconsideration decision and notify all of the parties of its decision or acknowledge the escalation notice in writing and forward the case file to the ALJ hearing office.

Jeffrey S. Baird, JD, is chairman of the Health Care Group at Brown & Fortunato PC, a law firm based in Amarillo, Tex. He represents pharmacies, infusion companies, HME companies, and other health care providers throughout the United States. Baird is Board Certified in Health Law by the Texas Board of Legal Specialization and can be reached at (806) 345-6320 or jbaird@bf-law.com.