tci Medicare Compliance & Reimbursement - 2015 Issue 20

Claims Appeals: Good News: You Now Have Better Appeal Chances for Certain Denied Claims

But make sure you pay attention to the many limitations on the new guidance. In a refreshing move from the Centers for Medicare & Medicaid Services (CMS), newly released guidance limits the scope of review for some redeterminations and reconsiderations. Now you’ll have a greater chance of winning appeals on Medicare claims denials. Scenario: Medicare paid your claim, but a Zone Program Integrity Contractor (ZPIC), Recovery Audit Contractor (RAC), Medicare Administrative Contractor (MAC), or Comprehensive Error Rate Testing (CERT) contractor reopened and reviewed the claim in a post-payment review or audit. The contractor decides to deny coverage of...

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