With more than 60 million beneficiaries, the Centers for Medicare &
Medicaid Services (CMS) processes more than 1 billion Medicare Part A
and Part B Fee-for-Service (FFS) claims each year. The vast majority of
these claims are processed without undergoing claims review, creating
vulnerability for the Medicare Trust Funds. Authorized by various
legislative actions, CMS has contracted with claims review entities to
perform post-payment and pre-payment claims review. Health care
providers and suppliers that have received a Medicare FFS claim denial
or overpayment determination may appeal the initial determination
through a five-stage uniform Part A and Part B appeals process.
This book provides an overview of the Medicare FFS audit and Medicare
appeals environment. It starts with an overview of the various CMS
contractors performing claims review (including post-payment and
pre-payment auditing activities). Then the Medicare Part A and Part B
appeals process is examined. Finally, appeal strategies are set forth
along with legal challenges applicable to Part A and Part B unfavorable
claims determinations, with which attorneys should familiarize
themselves when representing a health care entity subject to audit. A
list of resources and references is included at the conclusion of this
book.
