Appealing Medicare Denials – 5 Things You Must Know

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Physical Therapy Performance MeasuresAppealing Medicare denials is likely to be a reality for all outpatient therapy providers this year. Therapy over the $3700 cap is subject to 100% mandatory medical review by the Recovery Auditors (RACs) through 3/31/2013.  In fact those reviews, if not favorable, will first frustrate you, then possible anger you, then compel you to file an appeal.   Phones calls and emails today, from clients and non-clients reveal a growing frustration with the manual medical review process, some misunderstandings about the 10 day review in prepayment review states, and providers entering the appeals process that have a rude awaking on the two year backlog of appeals.  I covered that in this blog post on the ALJ Appellate Forum.  Let’s not take any more time and get right to the 5 things you must know when appealing Medicare denials.

Appealing Medicare Denials – Here are the “5″

  1. Medicare has formal appeals process, and your MAC will have interactive PDF forms and instructions to get you started.  Also check the CMS appeals website for complete rules and references.
  2. Recoupment (for post-payment review) will begin on the 41st day from the date of the demand letter if your MAC does not receive one of the following by the 30th day from the date of the demand letter: payment in full, a request for an extended repayment schedule. or a valid redetermination request
  3. If you use esMD (congratulations!) to submit to the RAC, you will have to go back to mail for the appeals process.  esMD is expanding to appeals in 2014, but we are not there yet.
  4. Organize all the documents and include a cover letter (last chance!) with a case executive summary (think of it as an excellent D/C report), a rebuttal of the denial as well as index of documents.  Strive to put items into evidence as early as you can in the appeals process.
  5. In spite of 24 – 30 month delay on ALJ hearings right now, appeal your case if you have deemed it defensible.  CMS collects data on appeals, and when you win (think positive), you will get interest on your payment.

Are you in appeals because of RAC denials?  Do you know that you will likely be in appeals because of pending ADRs?  What questions do you have?

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Nancy J. Beckley is the president of Nancy Beckley & Associates LLC, a firm specializing in outpatient therapy compliance. The firm offers compliance outsourcing, risk assessment, compliance plan development, annual compliance training, and external auditing, due diligence and investigation support. Clients include providers under Medicare probe review, progressive corrective action plans, corporate integrity agreements, ZPIC investigations and RAC audits.

Nancy’s background includes 15 years hospital experience serving in management capacities at two large inpatient rehabilitation facilities with extensive managed care contracting and program management expertise. A therapist by background and training, Nancy has served as program director, facility director and administrator in both inpatient and outpatient rehabilitation facilities.

She is a nationally known speaker in the area of rehab compliance, and has presented at the Provider Practice Compliance Conference, Florida Compliance Conference, and the Healthcare Compliance Association Compliance Institute. She was featured in a Healthcare Compliance Association webinar on Hospital Risks in Outpatient Therapy, and has authored three articles for Compliance Today and written over 20 articles on the RAC program.

Ms. Beckley’s area of expertise includes:

• Compliance program development, consulting, training, and external auditor

• Medicare regulatory requirements for outpatient therapy providers, including extensive experience in Medicare survey and certification for outpatient therapy providers

• Audit and consulting engagements under attorney-client privilege for risk assessment and potential payback liability analysis

• Medicare program integrity initiatives: MACs, RACs, CERT, ZPIC, probe reviews, pre and post payment reviews

• Nationally recognized expert on CORFs, served on the Medicare CORF Technical Expert Panel

• Hospital outpatient compliance consulting, auditing & training

• Compliance due diligence activities in acquisition and portfolio development to assess Medicare compliance risk

EDUCATION: University of South Florida, M.B.A.; Harvard University School of Public Health Course for Managed Care Executives; University of Illinois, M.S.; University of Wisconsin, B.S.

PROFESSIONAL ASSOCIATIONS: Board of Directors, National Association of Rehab Agencies (NARA); Member, Healthcare Compliance Association; Senior Contributing Editor, RAC Monitor + Monitor Mondays; Compliance Columnist for APTA’s IMPACT Journal

PROFESSIONALCERTIFICATIONS: CHC, Certified, Healthcare Compliance by the Healthcare Compliance Certification Board

PUBLICATIONS & PRESENTATIONS: Available upon request

CONTACT: 414-748-4376; [email protected];

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