It is not uncommon for healthcare providers to receive a demand for overpayment from Medicare. Those who find themselves in this situation may wonder what their options are. In some cases, it may make sense to pay the bill and move on. In others, the amount demanded by Medicare may be large enough and the reasoning questionable enough to warrant an appeal.
The appeal process consists of five levels: request for redetermination, request for reconsideration, request for an Office of Medicare Hearings and Appeals (OMHA) administrative law judge (ALJ) hearing, review by the Medicare Appeals Council (MAC) and a lawsuit in the federal court. The first two stages, redetermination and reconsideration, are essentially paperwork. The government requires these steps to move forward and a failure to do so correctly can get the appeal tossed out.
The third stage is where the action is, so to speak. During the third stage, the provider gets a chance to have their appeal heard before an independent arbiter. Those who make it this far can find success. A statistical expert that has provided expert testimony in these types of cases notes that the ALJ had found over half of the appeals decisions at this stage favorable for the provider. According to a recent piece by RAC monitor, a news source that focuses on healthcare issues, this expert reported 54.1% of appeals that made it before the ALJ hearing were dismissed, 16.6% found fully for the provider and 2% at least in part for the provider.
Those that make it this far could find the contractor chooses to appeal the ALJ’s finding to the MAC. It is helpful to discuss your options with experienced legal counsel whether reaching this stage or still deciding to take that first step. This can better ensure you understand the process and increase the likelihood of success.