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How to Win Medicare Appeals

“How to Win Medicare Appeals” provides a step-by-step guide through the maze of Medicare appeals. The goal of the book is to enable health care attorneys, Medicare providers (providers and suppliers), coders, billers, and Medicare billing companies to survive the maze and reach the Administrative Law Judge (ALJ) level of appeal, the only level of appeal where a provider can expect a truly neutral payment decision. The book is written in plain English so anyone can understand it the first time they read it.

Even if you don’t fit into one of the above work categories, here is why you should look at this book. Everyone has family members, friends, acquaintances, and colleagues who either provide Medicare services or represent people who do, and these folks are struggling with payment denials and demands for repayment of overpayments. Please forgive the lack of humility. I just wish I had this guide when I was a practicing surgeon, undergoing my own Medicare audit 20+ years ago (explained in the opening section of the book).

Why hasn’t a “how to” book like this been written previously? I frankly don’t know. What I am sure of is that Medicare appeals have become progressively more difficult and more adversarial over time. And you will not be surprised by the facts driving these changes. In 1966, when Medicare went into effect, there were 19 million Medicare beneficiaries and life expectancy for the average American was 70 years. By 2015, there were 55.5 million Medicare beneficiaries and life expectancy was 78.8 years.

In addition to three times as many beneficiaries and a significantly longer average life span, the annual cost of care for the average beneficiary has skyrocketed due to new technology (e.g. MRI studies, CT scans, artificial joints, etc.). In addition, the enhanced safety of general anesthesia enables Medicare beneficiaries to undergo procedures not considered reasonably safe in 1966.

While Congress expects Medicare to provide quality care for the Medicare beneficiaries, Congress cannot or will not provide Medicare with enough money to accomplish this goal. It should therefore come as no surprise that it is the providers who are being squeezed in this quality-of-care versus inadequate-funding dispute. Specifically, in response to less than optimal funding, CMS/Medicare is doing the only thing it can do and that is to tighten the billing rules for the Medicare providers.

One of the things that amazed me while writing this book was the apparent willingness of the providers to accept seemingly unacceptable billing rules without a peep of opposition. This apparent “go along to get along” view was expressed by providers I spoke with in every specialty during the more than five years spent on this project. I try to emphasize in the book that Medicare doesn’t like or dislike a provider or a provider’s specialty, a commonly held fear across all specialties. Medicare just doesn’t have the money to pay for the services provided for the beneficiaries.

Here is the answer to your next question: How bad is it out there? Unfortunately, we are now at the point where a violation of any billing rule, no matter how minor, will result in a Medicare conclusion of “improper payment.” As an example, even if a diabetic therapeutic shoe service enables a diabetic patient with an infected ulcer on the bottom the foot to heal the ulcer and avoid an amputation, or even loss of life, and even if all the patient care notes in the patient’s chart are complete - but one of Medicare’s separate “reporting” documents is found to be incomplete - all payments for that diabetic therapeutic shoe service are considered “improper” and the provider will receive a demand for repayment of overpayment after the services have been provided and after the provider has been paid.

The book answers all the following questions.

1. Why is it necessary for Medicare providers to stay current with the payment rules regarding the limited universe of services and/or supplies they provide?

2. Why do Medicare providers give up income they cannot afford to surrender as they fail to appeal erroneously denied claims?

3. Do Medicare providers invite closer scrutiny by Medicare when providers fail to appeal erroneously denied claims?

4. Will a simple spreadsheet enable a provider to keep current with all Medicare appeals?

5. What bad things happen when a Medicare provider procrastinates instead of quickly appealing erroneous denials?

6. Once the time limit for an appeal expires, why is it much, much harder for a provider to win an appeal?

7. How can a provider get an extension, get a dismissal reversed, or get a claim reopened?

8. What is the simple goal of a first level, redetermination appeal?

9. How did the second level, reconsideration appeal become the critical choke point in the appeals process?

10. What is a letter brief and how is it written for the QIC?

11. What are the five key questions that must be answered in the letter brief sent to the QIC?

12. What is a proposed decision and how is it different from the QIC letter brief?

13. How should a proposed decision be written for the ALJ?

14. How should a provider write, condense, and rehearse the oral presentation for the ALJ hearing?

15. How should a provider use the book's skeleton-outline letters during an appeal?



It is not all bad news. The ALJs who preside over the hearings are both competent and fair and, as long as the ALJs remain independent from the Centers for Medicare and Medicaid Services (CMS), the providers will have a viable defense against erroneous Medicare denials and erroneous Medicare demands for repayment of overpayment. In addition, these federally appointed, Medicare ALJs really do seek the correct outcome in Medicare payment disputes.


Whether you are a beginner or an expert at Medicare appeals, you should have "How to Win Medicare Appeals" opened to the page that explains how to do the very next thing you must do as you fight the erroneous denial in front of you.