Dealing with healthcare insurance payors is an arduous and complicated task. But trying to get federal healthcare agencies like Medicare, Medicaid, or others to pay for valid services performed when they unilaterally deny these claims can seem nearly hopeless. But fear not! The federal government has put processes in place to challenge these denials. However, as with all government bureaucracy, your legs might get tired jumping through the required hoops.
HOOP #1 – Appeal to the Agency That Denied the Claim. You need to first appeal your claim to the government entity that denied it. For example, if Medicare denied it, go to that entity’s appeals department. Payors are legally required to give the specific reasons for the denial, which you must address with the same specificity. So, have all your ducks in a row before you appeal. And be sure to address each reason for denial.
HOOP #2 – Take the Denied Appeal to Stage Two. If Medicare denies the appeal, you have the right to appeal to a Qualified Independent Contractor, or “QIC” (pronounced “Quick”). If the appeal involves Medical Advantage, the appeal goes to an Independent Review Entity (IRE). As with the first level appeal, you must specifically address each reason for denial and provide sufficient evidence to prove Medicare erred in its determinations.
HOOP #3 – Take the Matter Before an ALJ. If the second level independent reviewer still denies the claim, you can request an Administrative Law Judge (ALJ) hearing. An ALJ hearing in healthcare is a formal proceeding where an special judge reviews disputes between healthcare providers or beneficiaries and government agencies, primarily the Centers for Medicare & Medicaid Services (CMS) or other federal or state health programs. These hearings are an essential part of the process for resolving disputes related to Medicare, Medicaid, or other health insurance coverage, payment, or eligibility issues. When requesting this kind of hearing, you must include all the required information or it will not be considered complete and will cause unnecessary delays. The decision can take days or weeks, but if you are successful, the payor that denied the claim must then pay you all you are owed.
HOOP #4 – Take the Matter to a Medicare Appeals Council. The final option if your ALJ hearing does not prove successful is the Medicare Appeals Council. This is a body whose sole purpose is to determine whether or not Medicare actually owes you money – after all other appeals options fail. But because you did not prevail jumping through the other hoops, succeeding at the Appeals Council level is a very high bar to clear. Therefore, you will need to have clear and compelling evidence that your claim is justified and that the other appeals determinations were in gross error.
It is important to have legal counsel with specific experience in these processes to represent and guide you. The world of Medicare is difficult enough; don’t face the minefield of the appeals process on your own.