Five Levels of Appeal Available for Medicare RAC Overpayment Determinations
Providers, physicians and other suppliers who receive unfavorable overpayment determinations by Medicare Recovery Audit Contactors (“RACs”) for services and supplies provided to Medicare beneficiaries under Part A and Part B have up to five levels of appeal available to them. This process is exactly the same for all providers, physicians and suppliers who want to appeal a Medicare claim decision. The five levels of appeal are as follows:
1. Redetermination is performed by the claims processing contractor
2. Reconsideration is performed by the Qualified Independent Contractor (QIC)
3. Administrative Law Judge (“ALJ”) Hearing
4. Appeals Council Review
5. Final Judicial Review (Federal District Court Review)
First Level of Appeal: Redetermination
A redetermination is an examination of a claim by Medicare processing contractor personnel (i.e. Fiscal Intermediary; Medicare Administrative Contractor) who are different from the personnel who made the initial determination. The appellant (the individual filing the appeal) has 120 days from the date of receipt of the initial claim determination to file an appeal. A minimum monetary threshold is not required to request a redetermination.
Second Level of Appeal: Reconsideration
A party to the redetermination may request a reconsideration if dissatisfied with the redetermination. A Qualified Independent Contractor (“QIC”) will conduct the reconsideration. The QIC reconsideration process allows for an independent review of medical necessity issues by a panel of physicians or other health care professionals. A minimum monetary threshold is not required to request a reconsideration.
Third Level of Appeal: Administrative Law Judge Hearing
If at least $130.00 remains in controversy following the QIC’s decision, a party to the reconsideration may request an Administrative Law Judge (“ALJ”) hearing within 60 days of receipt of the reconsideration. Appellants must also send notice of the ALJ hearing request to all parties to the QIC reconsideration and verify this on the hearing request form or in the written request. The amount in controversy threshold for as of 2010 is $130.
Fourth Level of Appeal: Appeals Council Review
If a party to the ALJ hearing is dissatisfied with the ALJ’s decision, the party may request a review by the Appeals Council. There are no requirements regarding the amount of money in controversy. The request for Appeals Council review must be submitted in writing within 60 days of receipt of the ALJ’s decision, and must specify the issues and findings that are being contested.
Fifth Level of Appeal: Judicial Review in U.S. District Court
If at least $1,300.00 or more is still in controversy following the Appeals Council’s decision, a party to the decision may request judicial review before a U.S. District Court Judge. The appellant must file the request for review within 60 days of receipt of the Appeals Council’s decision. The amount in controversy required to request judicial review is increased annually by the percentage increase in the medical care component of the consumer price index for all urban consumers. The amount in controversy threshold for 2011 is $1,300.
For more information about the Medicare Appeals process, please see the Medicare Appeals Process brochure (pdf) issued by the Department of Health and Human Services, Centers for Medicare and Medicaid Services.
