Appealing an Audit
The word audit seems to put fear into the hearts of many physician practices across the country—but it shouldn’t. If you are prepared for an audit, your practice will run more smoothly from both a financial and personnel standpoint.
Due to the new appeals process and guidelines and the monetary level of appeals, you should consider the necessary resources and training your staff will need to appropriately respond to audits, as well as to appeal an unfavorable audit. The key to dealing with an audit is responding immediately to any correspondence that is received; even more important is appealing an adverse audit.
As soon as a “demand letter” is sent, the clock starts ticking, so disputing the audit findings of an overpayment should be done quickly. To appropriately appeal audits, it is vital to know and understand coding and documentation guidelines. Review all policies and regulations to stay abreast of changes and updates. Keep in mind that auditors must follow Medicare policies, national and local determinations, regulations, and manual instructions when performing a claims review. Additionally, minimize audit risks by performing self-audits quarterly or twice a year, because recovery audit contractors usually find issues with documentation.
The appeals process for a Medicare audit is a multistep process with filing deadlines attached to each level. Below is a step-by-step outline:
Appeal Guidelines
- Redetermination: Submit redetermination requests in writing within 120 calendar days of receiving notice of initial determination.
- 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.
- To avoid the recoupment on Day 41, the provider must submit a redetermination request in writing within 30 days of receipt of the letter.
- 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.
- 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.
- 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.
- Medicare Appeals Council Review: A Medicare Appeals Council (MAC) 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.
- 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 $1,350.
Remember, receiving an audit letter is nothing to fear as long as you are familiar with the audit process and understand coding and documentation guidelines.
