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Posts Tagged ‘appealing’

Challenging Physician Payment Sunshine Act Disclosures

Tuesday, June 27th, 2017

The Affordable Care Act added the Physician Payment Sunshine Act (Sunshine Act) as section 1128G to the Social Security Act. The Sunshine Act requires applicable manufacturers of drugs, devices, biologicals, or medical supplies and certain group purchasing organizations to report annually to the Centers for Medicare & Medicaid Services (CMS) certain payments or items of value that are provided to physicians and teaching hospitals.  The Sunshine Act also requires CMS to publish payments reported on a public Web site.

In 2013, CMS issued final regulations interpreting and clarifying the requirements of the Sunshine Act.  The final regulations clarify the reporting process, identify exceptions and exclusions from the reporting requirements, and provide further details regarding what constitutes a reportable relationship.  The final rule delineates the specific data elements reporting organizations are required to include and the required reporting format.  Reporting organizations failing to make required reports are subject to potential civil monetary penalties.  Continued

Part A Medicare Appeal Process Described

Monday, June 13th, 2011

Appealing Part A Adverse Reimbursement Determinations

Providers that are reimbursed under Medicare Part A have the opportunity to appeal adverse determinations of claims that they submit for payment.  There are two general types of appeals, depending upon whether a provider is appealing a claim or reimbursement under a cost report.

Medicare administrative contractors (“MACs”) review and process claims made under Medicare Part A.  When a claims determination is negative, the provider may appeal the decision within 120 days of the initial determination.  The provider requests a MAC for a redetermination of its claim.  Once the initial redetermination appeal is filed, the MAC has 60 days to make a redetermination.  The next step in the process is for the provider to request that a qualified independent contract (“QIC”) be appointed to reconsider the MAC’s denial.  The provider has a right to request a QIC review within 180 days following a negative redetermination by the MAC.  The QIC must render a reconsideration decision within 60 days following the provider’s request.

 

If the determination is still adverse to the provider, and if the amount in controversy exceeds a certain minimum amount, the provider may seek review of the claim by an administrative law judge (“ALJ”).  The request for administrative law judge review must be made within 60 days following the QIC’s determination.  The amount in controversy must exceed approximately $130.  Multiple controversies can be aggregated in order to meet this threshold the administrative law judge is required to submit a ruling within 90 days after the record of review is completed.

 

The next step for a provider who receives an adverse review by an administrative law judge is to request a review by the Medicare Appeals Council.  This review must be requested within 60 days of the ALJ’s ruling, and the Appeals Council must rule within 90 days after the request.

 

The last step for a provider assuming a continued negative result, is to file a claim with the Federal District Court.

 Procedures are different for appeals based upon adverse cost report determinations.  Cost report appeals are initiated when the MAC issues a notice of program reimbursement.  The notice of program reimbursement will include a determination of what costs are allowable and will identify any underpayment or overpayment due to or from the provider.  The provider is given 180 days from receipt of the notice of program reimbursement to file an appeal.  Where an amount in controversy is less than $10 the provider must appeal directly to the MAC.  For the smaller claim amounts the MAC decision will be reviewed by the administrator of CMS; however, there is no potential for judicial review of claims involving $10,000 or less.

The Provider Reimbursement Review Board (“PRRB”) hears cost report appeals where the dispute involves $10,000 or more.  PRRB decisions may be reviewed by the CMS administrator.  Amounts in controversy over $10,000 are also subject to court review.  This is just a brief summary of some of the appeal procedures for Part A providers.  Please contact our offices or speak with your usual health care attorney for more detail on these procedures.

John H. Fisher

Health Care Counsel
Ruder Ware, L.L.S.C.
500 First Street, Suite 8000
P.O. Box 8050
Wausau, WI 54402-8050

Tel 715.845.4336
Fax 715.845.2718

Ruder Ware is a member of Meritas Law Firms Worldwide

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