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Medicare claim appeals are appeals of the full or partial denial of one or more claims made to the Medicare program for payment for medical services furnished to a Medicare beneficiary. Appeals may be instituted by the beneficiary or by someone acting on the beneficiary's behalf, often a provider such as a SNF (see Medicare Provider) or supplier such as a physician (see Medicare Supplier). See also Assignment of Benefits (Medicare).
Typically, after the Initial Determination (see Initial Determination (Medicare), which is the initial determination by a Medicare Contractor that the claim should not be covered in whole or in part by the Medicare program. There are five stages of appeal. These are:
This process may differ somewhat in post-payment review of Medicare claims, in which case the "Initial Determination" may be called something else, such as an "Initial Determination of Overpayment" and may be made by a PSC, ZPIC, DME PSC, or RAC, sometimes resulting in a slightly different path to the ALJ stage of the claim appeal process. In the case of a post-payment review, the appellant is almost always a Medicare provider or supplier.
Broadly, the Due Process Clause of the 5th Amendment to the U.S. Constitution guarantees that no person shall be deprived of property without "due process of law." Because Medicare is a federal program under which citizens are entitled to property (i.e., disbursement of government funds, subject to certain requirements), denial of a claim under Medicare is a deprivation of property under the U.S. Constitution, and thus, is subject to some due process protections unless otherwise determined by Congress. In the case of the denial of a Medicare claim, these protections include the Medicare claim appeals process.
The amount-in-controversy restrictions were imposed upon the Medicare claim appeals process to limit the government's administrative burden of deciding appeals by limiting the appeals that can be heard at more advanced levels of the appeal process. [Citation needed]. This does not run afoul of the Due Process clause because Congress may limit the conditions under which citizens are entitled to disbursement of government property (i.e., money from the Medicare trust fund(s)) under a government program that Congress created. [Citation needed]. In this case, Congress has determined that at more advanced levels of the Medicare claim appeal process, citizens are not entitled to government property worth less than the amount in controversy limits. See 42 U.S.C. § 1395ff(b)(1)(E); 42 C.F.R. § 405.1006.
For many years, the Social Security Administration was responsible for hearing Medicare claim appeals at the Administrative Law Judge level, but this function began its transition to the Office of Medicare Hearings and Appeals effective July 1, 2005. See Medicare Modernization Act (MMA) § 931(b)(1) (Pub. L. 108-173); 70 Fed. Reg. 11420 (March 8, 2005).
Medicare claim appeals are currently governed by multiple statutes, primarily falling within Title XVIII of the Social Security Act (42 U.S.C. § 1395–1395iii).
42 U.S.C. § 1395ff specifically describes the appeals process itself, however, the legal issues arising in Medicare appeals can touch on almost any section of Title XVIII.
The regulations currently governing most procedural aspects of most Medicare claim appeals appear in 42 C.F.R. Part 405, Subpart I (§§ 405.900–405.1140). See 70 Fed. Reg. 11420, 11425 (March 8, 2005).
Agency guidance for Medicare claim appeals includes various Medicare Manuals, Local Coverage Determinations, National Coverage Determinations, and various other CMS publications.
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Issues in Medicare claim appeals commonly arise under 42 U.S.C. § 1395y(a)(1) ("medical necessity"), 42 U.S.C. § 1395gg ("waiver of liability"), 42 U.S.C. § 1395pp ("limitation of liability"), and 42 U.S.C. § 1395ddd ("statistically valid random sampling").
Aggregation of claims . . .
Consolidation of appeals . . .
Financial Liability . . .
Advance Beneficiary Notice . . .
Statistical sampling . . .
AHLA would like to thank Alex M. Hendler for drafting the initial content of this article.