Ghosting the Medicare Provider Appeals Process

The Medicare Providers Appeals process runs counter to the American judicial process.

In litigation, there are two opposing sides, as in football. It wouldn’t be much of a game if one side didn’t show up. In the case of Medicare provider appeals, only one side shows up and I am asking – how is that fair?

Let me explain: You, as a provider, receive a notice of Medicare overpayment in the mail. NGS or Palmetto or whoever claims you owe $4 million. Of course, the amount is extrapolated.

You decide to appeal.

The first level is a redetermination with the Medicare Administrative Contractor. It is a desk review; you do not have the opportunity to question the other side. It’s just a second look at the audit. The second level is the same as the first but performed by a Qualified Independent Contractor (QIC). This level is called a reconsideration. The third level you finally get before an administrative law judge (ALJ). Here, you envision the auditor presenting its evidence in support of why you owe $4 million, and you will be presenting evidence and support that you don’t owe the money.

You would be wrong.

The auditor may participate in an ALJ 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. No one is there to substantiate the allegation that you owe $4 million. Instead, you delivery a soliloquy as to why you don’t owe the money. The judge may ask you questions, but you won’t be cross examined nor will you have the opportunity to cross examine the auditor.

The Medicare provider appeal process flies in the face of America’s judicial system. Our rules allow the accused to confront the accuser. 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. The audits are accepted as true without any verification.

This process needs to be amended.

Medicare auditors should have to prove that their audits are accurate. They should have to prove that the documents didn’t support the claim billed and why. They should not be allowed to hide behind generic, cut-and-pasted denials without having to explain their reasoning, if there was any. This nonsensical, three-ring-circus is why providers refuse to accept Medicare.

In 2020, one percent of non-pediatric physicians formally opted out of Medicare. Of those opting out, 42 percent were psychiatrists.

This just goes to show you, qualifying for Medicare doesn’t guarantee that providers will accept you. It’s only going to get worse unless we change the appeal process for providers.

Programming Note: Listen to Knicole Emanuel’s live RAC Report every Monday on Monitor Mondays, 10 Eastern.