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MEDICARE APPEALS & MEDICARE AUDIT DEFENSE (TPE & UPIC)

OVERVIEW OF A WINNING MEDICARE APPEALS STRATEGY - 4 CRITICAL STEPS

With the TPE audit (and UPIC) program being in force nationwide, providers are tackling TPE audit defense and setting in motion a series of processes to successfully address TPE appeals.  First - and most importantly - is insuring compliance to all Medicare & Medicaid criteria. Proactive CMS compliance is crucial and will go along way to reducing the stress associated with periodic Medicare & Medicaid TPE & UPIC audits.  Next, is being able to successfully defend against TPE auditor denials, avoid potential CMS fraud allegations and hold on to your hard earned cash reserves.

​​​Settlement Conference Facilitation (SCF) is a pilot, alternative dispute resolution process designed to bring the provider and the Centers for Medicare & Medicaid Services (CMS) together to discuss the potential of a mutually agreeable resolution for claims appealed to the 3rd level (ALJ level) of the Medicare appeals process.  If a resolution is reached, a settlement document is drafted by the settlement conference facilitator to reflect the agreement.  The document is signed by the provider and CMS at the settlement conference session.  As part of the agreement, any future TPE audit defense and the request(s) for an ALJ hearing for the TPE claims covered by the settlement will be dismissed.  

The settlement conference facilitator uses mediation principles to assist the provider and CMS in working toward a mutually agreeable resolution.  The facilitator does not make official determinations on the merits of the claims at issue and does not serve as a fact finder, but may help the provider and CMS see the relative strengths and weaknesses of their positions.  The settlement conference facilitator is an employee of the Office of Medicare Hearings and Appeals (OMHA), which is a component of the Health and Human Services Office of the Secretary, and is organizationally and functionally separate from CMS.


Although all MEDICARE Part A provider types are eligible for the SCF pilot, the amount of each individual MEDICARE claim must be $100,000 or less (for the purposes of an extrapolated statistical sample, the overpayment amount extrapolated from the universe of claims must be $100,000 or less).


In addition to MEDICARE Part A, Phase II of the SCF pilot program has been underway for MEDICARE Part B since October, 2015. 


TPE AUDITS / UPIC AUDITS - OVERPAYMENT RECOUPMENT

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MEDICARE TPE & UPIC APPEALS - THE CMS ADMINISTRATIVE PROCESS

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At Jackson Davis, our core business is helping providers build winning RAC, TPE & UPIC audit defense strategies and win Medicare & Medicaid appeals cases.  We've been providing CMS compliance services for over 25 years.  We are passionate about what we do and wholly dedicated to our client's success.  We have worked with 100s of healthcare providers nationwide and assisted with 10,000+ Medicare and Medicaid appeals.

Contact us today at (303) 586-5003
Email us at support@upicaudits.com

​​1)  Several U.S. courts have held that a provider's adherence to CMS coverage criteria trumps all in the evaluation of claim denials.  In fact, the courts have held that - when Medicare & Medicaid coverage criteria exists for a given focus area - CMS MUST use the coverage criteria when evaluating claims for payment.  Nothing speaks louder in the UPIC appeals process than providers that painstakingly tie CMS coverage criteria to medical records documentation and present an evidence-based argument for payment.  On the other hand, using the "appeal everything" strategy - and not making internal operational changes to insure ongoing CMS compliance - is a guaranteed approach to facilitating potential Medicare & Medicaid fraud investigations.


2)  It is critical that providers file ALL supporting documentation relating to a given case no later than Stage II - Reconsideration (for MEDICARE cases).  After this stage, it can be extremely difficult to add supporting documentation to a case under administrative appeal and being heard by an ALJ.  When completing TPE or UPIC appeals and providing CMS compliance services for providers across-the-country, we have found a number of hybrid medical record systems, missing "other provider" documentation and significant holes in medical record documentation submitted for UPIC audit contractor review.

Jackson Davis Healthcare works directly with healthcare providers to build winning TPE APPEALS, UPIC appeals and enhance CMS compliance.  Attached is a great overview of the MEDICARE appeals process.

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First Level – Redetermination (Medicare Administrative Contractor) - TPE audit denials or overpayments must be initially reviewed (appealed) to the appropriate Medicare Administrative Contractor (MAC) by requesting a redetermination of the claim within 120 days of the Medicare's initial decision.  Medicare Administrative Contractors are required to respond to a provider’s request for redetermination within 60 days of receipt.

Second Level
– Reconsideration (Qualified Independent Contractor) - If a provider is dissatisfied with the outcome of the Level 1 appeal or redetermination process, a request for “reconsideration” may be filed with the appropriate Qualified Independent Contractor (QIC) within 180 days of the redetermination.  Requests for reconsideration are required to be processed within 60 days by the QIC (i.e. Maximus, C2C).  Although QICs used to be the first real chance at overturning a UPIC audit denial, today's QICs - Maximus and C2C - struggle with consistently understanding and applying Medicare coverage criteria.

Third Level – Administrative Law Judge Hearing - If a provider is not satisfied with Level 2 and the result of reconsideration, a hearing before an Administrative Law Judge (ALJ) can be requested.  The amount in controversy must be a minimum of $120 and requests for a hearing from an ALJ must be received within 60 days of the provider’s notice of the reconsideration outcome.  20 years ago providers were able to request and receive ALJ hearings within 60 to 90 days almost without exception.  Today, we are looking at 3+ years to even get an ALJ hearing scheduled.

Fourth Level – Medicare Appeals Council (MAC) - If the Level 3 appeal and decision by the ALJ is considered unfavorable by the provider, a fourth level appeal request may be filed with the Departmental Appeals Board (DAB) / Medicare Appeals Council (MAC).  Requests for a MAC review must be filed within 60 days of receipt of the ALJ’s decision.  The MAC must subsequently issue a determination within 90 days of the review. ** Remember: the MAC relies heavily on the providers understanding and adherence to Medicare coverage criteria.

Fifth Level – U.S. District Court Review - If the Level 4 decision of the MAC is deemed unfavorable to the provider, the final step in the appeals process is to file suit in U.S. District Court.  Requests must be filed within 60 days of the MACs decision and the amount in controversy must be at least $1,180.  As more and more providers get dealt grossly inappropriate outcomes through the Medicare appeals process, the courts (and juries) seem to be the best opportunity to get a fair & just review of the facts.

MEDICARE PART A APPEALS - SETTLEMENT CONFERENCE FACILITATION

CMS Transmittal 141 / CR 6183 specifically addressed a diverse range of MEDICARE appeals issues and discusses revisions to the MEDICARE appeals process.   Probably the most important aspect of Transmittal 141 is the timing of recoupment by CMS for overpayment determinations by contracted UPIC auditors.  In summary, time frames relating to the filing of appeals during the first 2 steps of the TPE appeals process have not changed (i.e. 120 days to file for redetermination and 180 days to file for reconsideration). However, in order to stop the automated recoupment of overpayments, providers MUST file TPE appeals within 30 days for redetermination and within 60 days for reconsideration.​​​

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Over the past 30 years, Jackson Davis Healthcare professionals have worked side-by-side with 100s of healthcare providers nationwide to build winning appeals for 10,000+ TPE audits, UPIC audits, RAC audits, ZPIC audits, MAC audits, PSC audits and a host of others.  We have built rock-solid Medicare & Medicaid audit defense cases for providers nationwide.  We have defended innocent providers facing fraud allegations from ZPIC auditors, the Office of Inspector General and the U.S. Attorney.  No one will work harder or give you a better chance to win than Jackson Davis… and we prove it every single day!

Our professionals have successfully challenged Medicare & Medicaid audit results through every step of the CMS appeals process and our record and reputation is unparalleled.  Time and again, we have assisted providers in building solid CMS audit defense cases for Redetermination / Reconsideration and successfully defended providers at ALJ hearings.  We are a passionate provider advocate and believe 100% that Medicare & Medicaid coverage criteria rules-the-day.  Our success fully encompasses healthcare providers across the U.S. and includes: hospitals & integrated delivery systems, hospices, home health agencies, inpatient rehab facilities, skilled nursing facilities, physician practices, DME providers and physical therapists.

3)  Remember - although each state differs slightly in the MEDICAID appeals process - an Administrative Law Judge (ALJ) hearing and the Medicare Appeals Council review are the last 2 administrative steps in the MEDICARE appeals process.  The Medicare Appeals Council relies heavily on Medicare coverage criteria in making decisions and their approach has shown time-and-time again that "legal or procedural" arguments are extremely difficult to win.


4)  Consider using independent auditors and physician experts to support YOUR case.  Most recently (i.e. FY 2017), the DOJ & HHS signed extensions for almost  $1.5B with NCI AdvanceMed to provide legal services and expert witness testimony to support CMS, UPIC audits and UPIC appeals.