Articles Posted in Medicare Appeals

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If you are appealing a reconsideration issued by a Qualified Independent Contractor (QIC) and you have not received a decision within 90 days you may have the right to have your appeal escalated to the next level before the Medicare Appeals Council.

An appellant who has properly filed a request for hearing before an Administrative Law Judge (ALJ) and whose appeal remains pending after 90 days may with certain restrictions, file a request with the Office of Medicare Hearings and Appeals (OMHA), to escalate the appeal to the Medicare Appeals Council. 42 C.F.R. 405.1016. If the request meets the requirements for escalation and the ALJ, or attorney administrator, does not issue a decision, dismissal order, or remand order, within five calendar days, or within 5 days from the end of the 90-day ALJ decision if the request is filed prematurely, the OMHA, will send a notice that the QIC reconsideration decision will be the decision that will be reviewed by the Council. The Council than has 180 calendar days to issue a decision, or dismissal or remand order. 42 C.F.R. 405.1106

The Council may take any of the following action subsequent to an escalation: Issue a decision based on the record before the QIC, and any additional information entered on the record before the ALJ; conduct any additional proceedings that the Council determines are necessary to issue a decision; remand the case back to the OMHA for further proceedings; dismiss the request for review because the appellant does not have the right to escalate the appeal; or dismiss the request for a hearing if the ALJ or attorney adjudicator could have dismissed the request. 42 C.F.R. 405.1108 Continue reading

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The Centers for Medicare and Medicaid Services (CMS) part of the Department of Health and Human Service (HHS) issued a final rule on January 17, 2017 titled “Medicare Program: Changes to the Medicare Claims and Entitlement, Medicare Advantage Organization Determination, and Medicare Prescription Drug Coverage Determination Appeals Procedures,” (Final Rule), that went into effect March 20, 2017. This Final Rule revised the appeal process before Administrative Law Judges. The Final Rule in its entirety can be found here. The new rule is designed to reduce the number of appeals and the time needed to adjudicate appeals before an ALJ, part of the Office of Medicare Hearings and Appeals, and the next level of appeal held before the Medicare Appeals Council, part of the Departmental Appeals Board. HHS hopes to eliminate the appeal backlog by fiscal year 2020.

The Final Rule will permit a Medicare Appeals Council’s decision to have precedential value to provide consistency, reduce resources need to adjudicate an appeal, and possibly reduce the number of appeals. It also allows attorney adjudicators to decide appeals without a hearing, review dismissals by a Qualified Independent Contractor (QIC), issue remands to CMS contractors, and dismiss a request for hearing when requested by the appellant. These changes will reduce the time that ALJs spend on administrative matters and allow more resources for conducting hearings. The Final Rule will also limit the number of CMS contractors that can participate in a hearing, improve administrative efficiency, by for example allowing an ALJ to vacate its own dismissal, and conduct most hearings via telephone (unless the appellant is an unrepresented beneficiary). Continue reading