Magazine article Medical Economics

Successfully Navigating the Medicare Enrollment Appeals Process

Magazine article Medical Economics

Successfully Navigating the Medicare Enrollment Appeals Process

Article excerpt

The Medicare enrollment process represents one of the federal government's primary lines of defense against health- care fraud. Although the process has existed in one form or another since Medicare's inception, in recent years it has now become a tool of the offense in denying access to those who would pilfer from the Medicare Trust Fund.

Unfortunately, for everyone else, otherwise well-meaning physicians can and do get caught in the tangled web that is the enrollment process, both at initial enrollment and in terms of maintaining enrollment.


If you run afoul of this system, you can appeal the final determinations of your status as a Medicare contractor, such as a denial or revocation of billing privileges, or when the effective date of such privileges is later than the physician expected. However, the appeals process itself can be daunting and fraught with potential snares. This article provides some background on the Medicare enrollment appeals process and explores some of the difficulties you can face.

The appeals process first becomes available to you after receiving a "final determination" from a Medicare administrative contractor (MAC). At this point, you may appeal the determination to the MAC by requesting a reconsideration. If the MAC rules against you, you may appeal the ruling to an administrative law judge (ALJ). If the ALJ rules against you, you may appeal to the Departmental Appeals Board (DAB). If the DAB rules against you, the decision may be appealed to federal court.

However, pursuing an appeal is not a simple affair; rather, it is a rigid, formal process where at each step, you must adhere to certain timeframes and requirements.


In general, at each step of the way, you have 60 days from the date of the letter notifying you of your appeal rights to submit an appeal. This clock is ticking even if you are otherwise in communication with the MAC, attempting to resolve the matter outside of the appeals process.

If the matter is not otherwise resolved within that 60- day window, you cannot then appeal; the window within which you can appeal is not open or extended merely because you are in communication with the MAC. A better course of action is for you to file an appeal even while also attempting to resolve the matter informally. This course will, at least, preserve your appeal rights.


On a related note, if you are communicating with the MAC, you cannot rely on the information the MAC provides. Federal courts have ruled that having followed bad advice from a government contractor does not protect against claims of wrongdoing. In other words, "but they told me to do it this way" is not an effective defense. You should therefore seek an attorney with expenenee in the appeals process, rather than going it alone.


You must undestand that both ALJs and the DAB apply rigid analyses to legal interpretations. What may seem a "mere technicality" to you is often a perfectly valid basis for a revocation or denial of billing privileges, or a delayed effective date.

For example, in several recent appeals cases, ALJs have upheld delayed effective dates based on such "technicalities."

In one case, a physician practice initially submitted an out-of-date version of the CMS85 5R reassignment form. The MAC promptly sent it back, instructing the physician to resubmit using the most current version of the form.

After the practice resubmitted the form, the MAC granted an effective date as of the date it received the second application. The practice challenged this determination, but the ALJ found in favor of the MAC.

In another case, an ambulatory surgical practice had its billing privileges revoked by the MAC because state law required a license to operate as an ambulatory surgical facility. The practice claimed that it had a permit from the state to perform ambulatory surgical services and therefore met the requirements. …

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