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CMS Appeals

Our Former Healthcare Fraud Enforcement Agents Assist Providers with CMS Appeals (Medicare Parts A, B, C, and D)

If your healthcare practice or company relies on Medicare reimbursements to stay in business, there is a good chance that, at some point, you will need to file a CMS appeal. The Centers for Medicare and Medicaid Services (CMS) strictly enforce compliance with the Medicare billing rules (including the different rules for Medicare Parts A, B, C, and D), and any apparent evidence of non-compliance can lead to denial of payment.

But, in many cases, CMS and its fee-for-service auditors get it wrong. The Medicare billing rules are complex, and assessing compliance isn’t easy—even for CMS. If you believe that CMS or one of its auditors has improperly denied payment or requested recoupments, your next course of action may be to file a CMS appeal.

5 Key Facts About CMS Appeals for Medicare-Participating Healthcare Providers

We assist healthcare providers and other Medicare participants nationwide with filing CMS appeals under Medicare Parts A, B, C, and D. In many cases, our team works alongside our clients’ legal counsel, offering our in-depth expertise in the area of Medicare billing compliance. While filing a CMS appeal can be important for protecting your practice’s or company’s finances, the process is complicated, and you must be prepared to affirmatively demonstrate why overturning CMS’s or its auditor’s determination is warranted.

For practitioners and executives who are considering an appeal, informed decision-making is essential. With this in mind, here are five key facts about CMS appeals involving Medicare reimbursement denials:

1. Medicare Parts A, B, C, and D All Have different Appeals Processes

The steps you need to take to file a CMS appeal depend on whether you are appealing a determination under Medicare Part A, B, C, or D. While Medicare Parts A and B have similar appeals processes, they are not identical. Part C and Part D each have unique appeals processes, and understanding how to navigate the process is a key first step toward securing a favorable result.

2. There Are Several Stages of CMS Appeals

Regardless of the type of appeal you need to file with CMS, you may need to go through multiple stages to secure a favorable outcome. While we have had significant success helping our clients achieve favorable outcomes at the initial stage, there are no guarantees. Ultimately, however, if your practice or company is facing unjust payment denials or recoupments, you should be able to secure a just result—and ensuring that you strictly follow the requisite procedures at each stage in the process will maximize your chances of an efficient resolution.

3. Informed Decision-Making is Critical When Considering a CMS Appeal

Due to the potential time and cost involved in pursuing a CMS appeal, informed decision-making is critical. If CMS’s or its auditor’s determination is valid, then your practice’s or company’s resources will be better spent on developing a compliance program for the future. On the other hand, if your practice or business is facing unwarranted billing-related penalties, then filing a successful appeal could be essential not only for securing payment for past billings, but for avoiding similar misguided allegations in the future.

4. Making Informed Decisions Requires Thorough Knowledge of the Relevant Medicare Billing Rules and CMS Appellate Procedures

To make informed decisions, you will need to have an in-depth understanding of both the relevant Medicare billing rules and the relevant CMS appellate procedures. At Fortis, we empower our clients with the information they need to act with their practice’s or company’s long-term best interests in mind. Our senior CMS appeals consultants will work with you directly to help you make the right decisions for your practice or business.

5. It Isn’t Unusual to Need to File a CMS Appeal

While it might seem like a rare occurrence to receive an incorrect determination of your practice’s or company’s right to reimbursement from Medicare, the reality is that incorrect determinations are commonplace. Auditors routinely make mistakes; and, while taking a proactive approach to defending against a healthcare audit can help prevent these mistakes from leading to adverse consequences, sometimes Medicare participants are left with no choice but to file an appeal.

Put our highly experienced team on your side

Dr. Stephen Taylor

DOL Consultant

Roger Bach

Former Special Agent (OIG)

Chris Quick

Former Special Agent

Kevin Smith

Former Assistant Regional Inspector General

Michael Koslow

Former Supervisory Special Agent (DOD-OIG)

James Hunt

Former Special Agent-in-Charge (DEA)

How We Help Healthcare Providers with CMS Appeals (Medicare Parts A, B, C, and D)

At Fortis, we provide comprehensive assistance with CMS appeals under Medicare Parts A, B, C, and D. From helping you decide whether to file an appeal to communicating with CMS or a fee-for-service auditor on your behalf, we can use our experience to help facilitate a favorable resolution. Our services for healthcare providers and companies that are considering CMS appeals include:

  • Assessing All Potential Grounds for Filing a CMS Appeal – With our extensive experience in the area of Medicare billing compliance, we can assess all potential grounds for filing a CMS appeal. This includes everything from misinterpretation and misapplication of the relevant Medicare billing rules to violations of CMS fee-for-service auditors’ restrictions and responsibilities.
  • Documenting the Flaws in the Appeals Process or Determination – Once we determine how best to challenge the outcome of your CMS audit, we will thoroughly document the flaws in the appeals process, the final determination, or both. Our consultants can also serve as expert witnesses to provide testimony in support of your practice’s or company’s appeal if necessary.
  • Communicating with Auditors or CMS Directly – In many cases, we can communicate directly with auditors or CMS personnels to address flaws in our clients’ audits. If we can communicate directly with auditors or CMS personnel to expose flaws in your audit, this may facilitate a swift and extremely cost-effective resolution.
  • Assisting Legal Counsel During the CMS Appeals Process – When our clients need to go through the formal CMS appeals process, we assist our clients’ legal counsel as necessary. In addition to preparing reports and providing expert testimony, we also serve as consultants to help our clients’ counsel craft clear arguments and effective litigation strategies.
  • Implementing Safeguards to Prevent the Need for Future Appeals – We also help our clients implement safeguards to prevent the need for future appeals. By helping our clients ensure that they thoroughly document their Medicare billing compliance efforts on an ongoing basis, we are able to provide them with the tools and resources they need to efficiently deal with audits and other inquiries in the future.

What Can You Expect from Your CMS Appeal (Medicare Part A, B, C, or D)?

Let’s say that your healthcare practice or business is dealing with an unfavorable Medicare audit determination, and its best course of action is to file a CMS appeal. What can you expect as you move forward?

The short answer is, “It depends.” From the issues you need to appeal to the type of appeal you need to file, there are several factors that will influence what you can expect during the process. At Fortis, our CMS appeals consultants can conduct a comprehensive assessment so that you can make informed decisions about your next steps. Depending on what those next steps are, we can also explain what you can expect based on our experience—including the likelihood of success at each stage of the appeals process.

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FAQs: What Healthcare Providers Need to Know About CMS Appeals

When Should I Consider Filing a CMS Appeal?

You should consider filing a CMS appeal if you have any reason to believe that your healthcare practice or company has been improperly denied Medicare reimbursement. Improper denials are not uncommon, and the appeals process exists to provide Medicare participants with an avenue to seek redress when necessary.

How Do I File a Successful CMS Appeal?

Filing a successful CMS appeal starts with clearly identifying the grounds for challenging the outcome of your practice’s or company’s Medicare audit. Once you identify these grounds, then you can use your practice’s or company’s billing records to build a strong case for reversing an unfavorable audit determination.

How Long Do CMS Appeals Typically Take?

The timeframe for a CMS appeal depends on the specific type of appeal you need to file (i.e., Medicare Part A, B, C, or D). For example, while Medicare Administrative Contractors (MACs) must generally make redeterminations within 60 days under Medicare Parts A and B, the process can take significantly longer in some cases.

What is the Likelihood of a Successful Outcome from a CMS Appeal?

The likelihood of success in a CMS appeal depends entirely on the circumstances involved. If your practice or company has clear and well-documented grounds for challenging the outcome of its Medicare audit, then you should be able to secure a favorable resolution.

Why Is It Important to Hire a CMS Appeals Consulting Firm?

Hiring a CMS appeals consulting firm is essential for ensuring that you are making informed decisions. Additionally, many law firms lack the knowledge and resources required to fully handle CMS appeals in-house. At Fortis, we work with our clients to help them achieve favorable results without pursuing formal legal means whenever possible, and we work alongside our clients’ legal counsel when necessary.

Schedule a Complimentary Consultation with a CMS Appeals Consultant at Fortis

If you need to know more about filing a CMS appeal following an unfavorable Medicare audit, we encourage you to get in touch. Please call 866-808-4160 or tell us how we can reach you online to schedule a complimentary consultation today.