LTC Matters: Restructuring of the Medicare Appeals Process: Are Long Term Care Providers Ready?
5/1/2005
Given the uncertain (and sometimes hostile) Medicare reimbursement environment, Skilled Nursing Facilities must prepare for the imminent changes in the Medicare appeals system to maintain current Medicare reimbursement revenues. On March 1, 2005, Centers for Medicare and Medicaid Services published a long-awaited interim final rule (the Rule) making sweeping changes to the process for appealing adverse actions related to Medicare fee-for-service claims. These new regulations are particularly significant because they unify the appeal processes for Part A and Part B claims, to which different appeal procedures apply until the first significant stage of implementation begins on May 1, 2005. Other important aspects of the Rule, all of which are discussed in this publication, include the following:
- processing of second-level appeals by a new independent entity;
- mandatory submission of all evidence early in the appeals process, except in limited circumstances;
- administrative law judge (ALJ) hearings conducted via videoteleconferencing rather than in person;
- party status for the CMS in ALJ hearings; and
- substantial deference to CMS guidance for ALJs.
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