Andrew B. Wachler, Esq. of Wachler & Associates, P.C. offers a few considerations for providers facing the redetermination and reconsideration levels of RAC appeal below.
At both redetermination and reconsideration, providers have the ability to limit CMS' recoupment of the alleged overpayment. Under the regulations, providers who are dissatisfied with an initial determination have 120 days to file for redetermination. But CMS may start recouping the alleged overpayment from the provider on the 41st day after the initial determination or demand letter. Recoupment may be stopped at redetermination if the provider files a request for redetermination with 30 days of receiving the initial overpayment.
At the reconsideration level, providers have 180 days to submit a request for reconsideration, but again, CMS may start recouping the alleged overpayment on the 76th day after the redetermination decision. In order to avoid recoupment, providers must file their request for reconsideration within 60 days of receiving their redetermination decision. Preventing recoupment is an important consideration for many providers and requires that the requests be filed in a timely manner. If you plan to consult with outside counsel for your appeals, you will want to make sure to involve them early, and to get them the information related to the appeal as soon as possible so that they may prepare your requests timely.
Another important consideration at the reconsideration level of appeal is the early presentation of evidence requirement. The requirement states that absent good cause, failure to submit all evidence precludes subsequent consideration of that evidence. Thus, when filing your reconsideration request you will want to make sure that all documentation and evidence that supports the claim has been filed before the reconsideration decision is issued. Given the potential impact of the early presentation of evidence requirement, it is important to retain or consult with counsel prior to the reconsideration stage in order to develop a strategic approach for the submission of evidence.
If it is possible to organize this information at the time you are preparing your request for reconsideration, it is ideal to submit it then. If you submit your request within 60 days in order to prevent recoupment but are not able to prepare the evidence and/or written analysis within the 60 day time frame, you will want to ensure you submit this information before the decision is issued. This may be the case with more complex appeals involving multiple beneficiaries and a large volume of medical records. The regulations require that the QIC issued a reconsideration decision within 60 days of receiving a request reconsideration.
Thus, it is extremely important to submit any additional information that was not previously submitted well before the 60 day timeframe for the decision has run. Cautiously serially submitting documentation during the 60 day decision-making time may be helpful in some cases, but there is no guarantee that the QIC will extend the timeframe. Each time a provider submits additional documentation, the QIC may extent the time for its decision by 14 days. This additional time may be helpful in a complex case.
These are just a few of the considerations providers should be aware of when appealing denials at the redetermination and reconsideration levels.
Publication Date: Thursday, February 25, 2010