Reimbursement Page By Devon Bernard
Exercise Your Right to Appeal Make the time to appeal a RAC recoupment request
ith prepayment audits resulting in claim denials and other audits resulting in overpayment requests (a return of monies on a previously paid claim), your right to appeal is becoming more important and more valuable than ever.
Worth Your Time In its Fiscal Year 2011 Report to Congress, the Centers for Medicare and Medicaid Services (CMS) stated that the four Recovery Audit Contractors (RACs) identified a total of 903,372 Medicare claims as overpayments and issued recoupment requests. Out of those 903,372 claims, only 60,717 were appealed. This represents an appeal rate of just more than 6 percent—in other words, more than 93 percent of the overpayments were not contested. This appeal rate benefits the RACs since they are paid on a contingency basis. The RACs are counting on you to not appeal their findings. If you win an appeal, the RACs don’t keep their contingency fee. What is even more interesting is that, of the 60,717 claims that were
O&P Almanac JULY 2013
appealed, 43 percent were eventually overturned in the providers’ favor. This represents a substantial success rate of overturning a RAC recoupment request for those who take the time to go through the appeal process. While the statistics do not provide any O&P-specific information, they do illustrate the value in pursuing the appeal process. Regardless of the “what” (denial/ nonpayment or overpayment request) or “why” (RAC audit, prepayment review, etc.) of an appeal, the process remains basically the same—you will have to navigate through the five official levels of appeals.
Level 1: Redetermination Redetermination is the first level of appeal. After you receive an unfavorable determination on a claim, you have 120 days to file an appeal in writing. Once a request for redetermination is submitted, it will be reviewed by someone other than the person who made the initial determination, but it will be reviewed by the Durable
Medical Equipment Medicare Administrative Contractor (DME MAC) that processed the initial claim. You should receive a response within 45 days, although it may take up to 60 days.
Level 2: Reconsideration If your appeal is unsuccessful at the redetermination stage, the next step is to request reconsideration. At this level, your claim will no longer be reviewed by the DME MAC that originally processed your claim. Instead, it will be reviewed by an outside Qualified Independent Contractor (QIC), which is currently designated as C2C Solutions Inc. All reconsideration requests must be made in writing and within 180 days of receipt of the redetermination decision. This is the last level of appeal where you may submit additional or new documentation supporting your assertion that the claim denial/overpayment request should be overturned; after this level, no new documentation can be submitted unless you can prove or