HomeLearnThe RAC Appeals Process

Submitted Courtesy of Wachler & Associates, P.C.

If your organization receives a claim denial or overpayment demand as a result of a RAC review or other Medicare audit, you can appeal this decision through the uniform Medicare Part A and Part B appeals process. The five-stage Medicare appeals process is summarized below.

The first level in the appeals process is redetermination. A request for redetermination must be filed in writing within 120 calendar days of receiving notice of initial determination. There is no amount in controversy requirement.

Note: Although a provider or supplier has 120 days to file this first level of appeal, Medicare will begin withholding or recouping Medicare funds before the time frame for appeal has elapsed. In many cases, Medicare will begin withholding or recouping Medicare funds 30 days following the date of initial decision, unless the provider or supplier first appeals.

The second level in the appeals process is reconsideration to be conducted by a Qualified Independent Contractor (QIC). This second level of appeal must be filed within 180 calendar days of receiving notice of the redetermination decision. There also is no amount in controversy requirement for this stage of appeal.

Note: Although a provider or supplier has 180 days to file this second level of appeal, Medicare will begin withholding or recouping Medicare funds before the time frame for appeal has elapsed. Medicare will begin withholding or recouping Medicare funds 60 days following the date of redetermination decision, unless the provider or supplier first appeals.

Although it may be tempting for providers and suppliers to quickly appeal an unfavorable redetermination decision to stop Medicare from withholding funds, it may be advantageous for the provider or supplier to take additional time to carefully put together an appeal. The regulations require providers and suppliers to present all evidence, allegations of fact or law related to the issues in dispute, and explain their reasons for disagreement when filing a reconsideration request. Absent good cause, the failure to submit this evidence prior to issuance of the reconsideration decision precludes subsequent consideration of the evidence. Our lawyers can assist your organization to prepare an appropriate appeals strategy.

The third level of appeal is Administrative Law Judge (ALJ) hearing. This request must be filed within 60 days following receipt of the QIC’s reconsideration decision. This request must meet an amount in controversy requirement.

The fourth level of appeal is the Medicare Appeals Council (MAC) Review. The MAC is within the Department Appeals Board of the U.S. Department of Health and Human Services. A MAC Review must be filed within 60 days following receipt of the ALJ’s decision and meet an amount in controversy requirement.

The final step in the Medicare appeals process is review in Federal District Court.  An appeal to federal district court must be filed within 60 days from the receipt of the MAC’s decision, and must meet an amount in controversy requirement.

Submitted courtesy Wachler & Associates, P.C.
210 East 3rd Street Suite 204
Royal Oak, MI 48067

500 Griswold Suite 2400
Detroit, MI 48226

Phone: 248-544-0888
Fax: 248-544-3111

Main website: www.wachler.com
Specialty audit website:  www.racattorney.com

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