As Michael Crouch detailed in his 3-part guest blog on CarolineFifeMD.com, Medicare providers under audit may face a lengthy administrative appeals process before obtaining a hearing or review by an Administrative Law Judge (ALJ):
- The Incredible Journey: Lessons Learned from a “Skin Substitute Graft” Audit – Part One – Caroline Fife M.D.
- Here Comes the Judge! Part 2 of the Incredible Journey of a Skin Substitute Audit – Guest Blog by Michael Crouch
- The Incredible Journey: Lessons Learned from a Skin Substitute Graft Audit (Part Three)
The Medicare appeals process generally proceeds through multiple levels: redetermination by the Medicare Administrative Contractor (MAC), reconsideration by a Qualified Independent Contractor (QIC), and then a hearing before an ALJ. After the ALJ, the case can be reviewed by the Medicare Appeals Council (Council). I thought that the Council was the last stop on the audit bus – but it might not be. Although the Council is organizationally separate from CMS, it remains part of the administrative review process within the Department of Health and Human Services (DHHS).
Attorney Knicole Emanuel has posted a blog explaining that under some circumstances, an appeals case can be escalated to a Federal District Court when administrative deadlines are not met. A federal court is entirely outside CMS’s administrative structure because they are part of the independent Judicial Branch established under Article III of the Constitution, providing review by judges who are not part of the Medicare administrative system.
You need to read her entire blog because the details matter. As Ms. Emanuel explains, “Providers should recognize, however, that escalation is not available simply because they disagree with an administrative decision or prefer a judicial forum. The right to escalate arises only when the Council fails to issue a timely decision within the regulatory adjudication period. Careful monitoring of appeal deadlines and preservation of procedural rights are therefore essential throughout the administrative process.”
