Medicare ZPIC Appeals

Jackson Davis HealthCare (JDH) provides the nation's most comprehensive, efficient & effective defense for Medicare appeals and Medicare fraud issues.  Over the past 25 years, Jackson Davis professionals have worked with providers and attorneys nationwide to address 1,000s of CMS overpayment issues.  As your unwavering advocate, Jackson Davis HealthCare (JDH) leads the nation in building CMS criteria-based cases and developing winning Medicare appeals.  In order to maintain attorney-client privilege throughout the ZPIC appeals process, JDH partners with leading national and international law firms to establish codified work-product relationships.  We have established working relationships with the nation's best attorneys and recommend the most experienced attorney(s) for your specific circumstance.

Medicare ZPIC Appeals - Process & Overview

1)  Step 1 - CMS Criteria-Based Case Review

Jackson Davis HealthCare physicians, nurses, billing compliance professionals and legal services staff will evaluate each denial / overpayment determination case and compare the underlying documentation to required Medicare coverage criteria.  CMS criteria-based case reviews includes the evaluation of underlying clinical considerations, supporting medical records documentation, CMS evidence-based payment criteria and estimated financial impact.

2)  Step 2 - Prepare CMS Criteria-Based Case Summary & ZPIC Appeal

Based upon the outcome of the CMS criteria-based case review, we prepare all medical records, required CMS supporting documentation and a CMS criteria-based case summary to accompany the submission to the Medicare Administrative Contractor (MAC).

3)  Step 3 - Submit ZPIC Appeal - CMS Required Documentation

Submit all required CMS documentation to the Medicare Administrative Contractor and coordinate with provider staff and selected legal counsel throughout the redetermination & reconsideration process (Medicare appeals - stages 1 & 2).  Medicare appeals must be initially filed within 30 days of denial in order to stop the recoupment process.

4)  Step 4 - Coordinate with Legal Counsel at Reconsideration

If the provider's appeal efforts are not initially successful in the redetermination stage, JDH professionals will work collaboratively with select health law firms in each Medicare region to most effectively and aggressively challenge Medicare audits recoupment throughout the remaining steps of the Medicare appeals process.

5)  Step 5 - Provide CMS Regulatory & Clinical Expert Testimony

If the provider's appeal efforts are not successful during the initial 2 stages, JDH provides a full range of expert regulatory & clinical testimony in support of a provider's adherence to Medicare coverage criteria at ALJ hearings and or subsequent judicial proceedings.

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The following information MUST be included with your request for all appeal levels:

Beneficiary name
Medicare Health Insurance Claim (HIC) Number
Specific service(s) and/or item(s) for which the redetermination / reconsideration is being requested
Specific date(s) of the service; and
Name and signature of the provider or the representative of the provider

First Level – Redetermination (Medicare Administrative Contractor)

Claim denials or overpayments must be initially reviewed (appealed) to the appropriate Medicare Administrative Contractor (MAC) by requesting a redetermination of the claim within 120 days of the Medicare contractors initial decision.  Medicare Administrative Contractors are required to respond to a provider’s request for redetermination within 60 days of receipt.

Second Level – Reconsideration (Qualified Independent Contractor)

If a provider is dissatisfied with the outcome of the Level 1 appeal or redetermination process, a request for “reconsideration” may be filed with the appropriate Qualified Independent Contractor (QIC) within 180 days of the redetermination.  Requests for reconsideration are required to be processed within 60 days by the QIC.

Third Level – Administrative Law Judge Hearing

If a provider is not satisfied with Level 2 and the result of reconsideration, a hearing before an Administrative Law Judge (ALJ) can be requested.  The amount in controversy must be a minimum of $120 and requests for a hearing from an ALJ must be received within 60 days of the provider’s notice of the reconsideration outcome.

Fourth Level – Medicare Appeals Council (MAC)

If the Level 3 appeal and decision by the ALJ is considered unfavorable by the provider, a fourth level appeal request may be filed with the Departmental Appeals Board (DAB) / Medicare Appeals Council (MAC).  Requests for a MAC review must be filed within 60 days of receipt of the ALJ’s decision.  The MAC must subsequently issue a determination within 90 days of the review.

Fifth Level – U.S. District Court Review

If the Level 4 decision of the MAC is deemed unfavorable to the provider, the final step in the appeals process is to file suit in U.S. District Court.  Requests must be filed within 60 days of the MACs decision and the amount in controversy must be at least $1,180.

CMS Transmittal 141 - Limitation on the Recoupment of Medicare Audit Overpayment Determinations

CMS Transmittal 141 specifically addresses a diverse range of Medicare appeals issues and discusses revisions to the Medicare appeals process.   Probably the most important aspect of Transmittal 141 is the timing of recoupment by CMS for overpayment determinations by contracted Medicare auditors.

In summary, time frames relating to the filing of Medicare appeals during the first 2 steps of the Medicare appeals process have not changed (i.e. 120 days to file for redetermination and 180 days to file for reconsideration).  However, in order to stop the automated recoupment of overpayments, providers MUST file Medicare appeals within 30 days for redetermination and within 60 days for reconsideration.