Rheumatology Practice Pearls: Appealing an Audit

The appeals process for a Medicare or Recovery Audit Contractor audit is a multistep process with filing deadlines attached to each level. Below is a step-by-step outline:

Appeal Guidelines

1. Redetermination: Submit redetermination requests in writing within 120 calendar days of receiving notice of initial determination.
   1. If the appeal is not requested by the 30th day of the demand letter and no overpayment has been returned, an automatic recoupment will begin on Day 41 of receiving the demand letter.
   2. To avoid the recoupment on Day 41, the provider must submit a redetermination request in writing within 30 days of receipt of the letter.
   3. If the request for an appeal is received after the 30 days and the recoupment began on Day 41, the recoupment will be halted until a determination can be made.
2. Reconsideration: If you don’t agree with the carrier’s redetermination decision, you may file for reconsideration to be conducted by a Qualified Independent Contractor (QIC). This level of appeal must be filed within 180 calendar days of receiving notice of the redetermination decision from the QIC.
   If the findings are still in concurrence with the redetermination, submit the second level of appeal request to the QIC within 60 calendar days to avoid the recoupment restarting.
3. Administrative Law Judge Hearing: If you are dissatisfied with a reconsideration decision or choose to exercise the escalation provision during the reconsideration stage, you may request an Administrative Law Judge Hearing. The request must be filed within 60 days following the receipt of the QIC’s decision. There must be at least $130 in dispute.
4. Medicare Appeals Council Review: A Medicare Appeals Council Review request must be filed within 60 calendar days following the receipt of the Administrative Law Judge’s decision. The Medicare Appeals Council review must classify and explain the parts of the Administrative Law Judge’s action that are in disagreement. There must be at least $130 in dispute.
5. Federal District Court: This is the final step in the appeals process. A request for a review in the district court must be filed within 60 calendar days of the receipt of the MAC’s decision. The disputed amount must be at least $1,260.

For additional information, contact Melesia Tillman at [email protected] or (404) 633-3777, ext. 820.