A Favorable, New Climate for Challenging Medicare Appeals

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Over the past decade, health care providers seeking to challenge Medicare claim denials have faced increasing delays in reaching what many consider the most important step in the Medicare appeals process - a hearing before an impartial administrative law judge (‘‘ALJ’’) (the prior two steps are decided by Medicare contractors who often have a financial interest adverse to that of the provider). Strikingly, providers succeed at overturning denials more than half of the time according to CMS’s 2014 data—and even more frequently in previous years — while individual provider data suggests success rates are often much higher than 54%.

Originally published in Bloomberg BNA’s Medicare Report, 27 MCR 737, 8/12/16.

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DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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