The Medicare appeals process today continues to be challenged by an ever-increasing number of appeals and insufficient resources. Providers and suppliers believe that to receive a proper and complete adjudication of their claims for Medicare payment, cases need to be appealed to the Administrative Law Judge (ALJ) and Medicare Appeals Council levels of review. It is at the ALJ level that a provider or supplier can present expert testimony regarding the medical condition of a beneficiary, as well as explain medical records and related documentation supporting payment of a claim. The following issues are typically adjudicated at the ALJ level:
CMS announced final regulatory changes affecting Medicare Advantage and Part D May 19. This final rule is significant not only for the new regulations now implemented, but also for the proposed changes that CMS declined to adopt due to unprecedented controversy and backlash.
Editor's note: This month's "Q&A" was modified from the HCPro book Finance, Budgeting, and Quantitative Analysis, written by Brian Garavaglia, PhD, FACHCA. Finance, Budgeting, and Quantitative Analysis is a comprehensive guide designed specifically to help long-term care managers produce, present, and defend their budget. For more information or to order, call customer service at 800-650-6787 or visit www.hcmarketplace.com. To submit a question for upcoming issues, email Managing Editor Olivia MacDonald at email@example.com.