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Friday, October 4, 2013

Medicare Appeal Success Rates Trending Down

by James Swann

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If you're thinking of appealing a denied Medicare claim, you might want to ready yourself for some disappointment, especially if it's a Medicare Part A claim. Only 24 percent of appealed Medicare Part A claims were overturned at the first level of the Medicare appeals process in 2012, compared with 50 percent of Part A claims in 2008, according to a recent OIG report. Appealed Part A claims that were denied due to a Recovery Audit Contractor review had an even steeper drop-off in the overturn rate, moving from 83 percent in 2009 to 11 percent in 2012 (the RAC program was fully implemented in 2009). The overturn rate for first level Medicare Part B appeals dropped from 65 percent in 2008 to 51 percent in 2012, the report said.

First level Medicare appeals are also known as redeterminations, and beneficiaries and providers must file a request for redetermination with their Medicare Administrative Contractor within 120 days of receiving notice of a claim determination. If the redetermination is unsuccessful, beneficiaries and providers can move to the next level of the Medicare appeals process, which involves claim reconsideration by a Qualified Independent Contractor. The OIG said the overall number of Medicare redeterminations grew by 33 percent between 2008 and 2012, from 2.2 million in 2008 to 2.9 million in 2012.
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