Medicare Appeals Council
Overview:
The fifth level of appeal involves a coverage decision by the Medicare Appeals council.
If an Administrative Law Judge (ALJ) issues an adverse decision, the Provider may appeal the decision by requesting a review by the Medicare Appeals Council (Appeals Council).
To request that the Medicare Appeals Council (Appeals Council) review the ALJ's decision the provider must follow directions provided in the ALJ's hearing decision. The Appeal Council will review all of the evidence and issue a determination. This level will be most complex, as the rationale for coverage has been stated by the Provider during multiple appeal levels and the provider must illuminate to the Council why they continue to opine that the services provided were medically reasonable and necessary and compliantly provided within the Medicare guidelines.
Harmony works with Providers to seek verbiage and rational to present to the Appeal Council through staff interviews and assessment of Medical records for the time period in question. Harmony offers intimacy with regulations governing the SNF setting as well as a tactical approach to managing this level of appeal to bring the appeal to finality and successfully overturning the denied decision.
Potential Risk to Providers:
Once a request is successfully positioned at the Appeals Council level, the Appeals Council will review the ALJ's decision along with the entire case file, and any additional evidence submitted. The Council will look to see if the ALJ committed any legal or procedural errors and whether all of the evidence was properly considered.
Upon review, the Appeals Council can perform one of three options:
- Deny the Request for Review (take no action on the case). Providers still have options if this occurs.
- Remand the case to the ALJ (return the case back to the ALJ for a new decision). This will typically mean another hearing with the ALJ
- Issue a new decision favorable on behalf of the provider.
Denied claims which are unsuccessfully tried at the ALJ level continue to place providers at risk for additional Medical Record Reviews. Intricate review of the details and application of the Federal regulations in the ALJ decision is recommended for investigation for potential misappropriation of the Medicare Regulations.
How can Harmony (HHI) help?
Harmony Denied Claim Experts provide
- Education for team members on Medicare Coverage guidelines with insight specifically related to the denied claim at hand.
- Coaching sessions for facility team members to prepare for this level of appeal
- Review of the medical record documentation and any associated documents to further explore rational for proving full coverage of the claim.
- Explanation statement for submission to the Appeals Council with additional support for skilled services provided.
