Medicare Appeals Process Needs Changes

Medicare Appeals Process Needs to be Amended

In her recent article, “Ghosting the Medicare Provider Appeals Process,” Knicole C. Emanuel Esq. argues that the process by which denied Medicare claims are reviewed and appealed is counter to rest of the U.S. legal system.

The lengthy process for addressing denied Medicare claims is multi-tiered and, until recently, hampered by a years-long backlog due to a shortage of judges. Yet those issues are not the true problem. The problem lies in the fact that the process is one-sided. “At no time during your Medicare appeal do you get to challenge the auditor nor does the auditor have to back up his or her work,” Emanuel writes. “The audits are accepted as true without any verification. … The auditor may participate in an ALJ (administrative law judge) Hearing. However, in my experience, the auditors never show up. They don’t provide evidence that their extrapolation was accurate or that their clinical findings are precise.”

Our experience at AppriseMD reflects that of Ms. Emanuel’s when it comes to appeals taken through the Medicare Appeals Process.  One case AppriseMD argued in front of an ALJ was just as described, with no appearance, rebuttal or explanation by either of the two Recovery Audit Contractors who denied the claim for which we were appealing. We ultimately had the denial reversed, but we concur that the process needs to be amended as it is not congruous with the American judicial system.

While we were pleased with the outcome we achieved, it is never a good idea to have a one-sided judicial process that is not balanced and fair.

Read more about the AppriseMD ALJ case here.

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