Medicare Lien Appeals – The Five Levels

If you either (a) failed in your attempts to dispute MSPRC Conditional Payment Summaries, or, (b) simply did not dispute the Medicare lien prior to settlement, you have a series of options to reduce the client’s Medicare lien.

While it isn’t really negotiating, we nonetheless term it, Negotiating With Medicare.  The negotiation options:

  1. Compromise with the Centers for Medicare & Medicaid Services (“CMS”).  This can be done both before settlement (when you have a proposal on the table, but where the Medicare lien exceeds your client’s take-home) and after settlement.
  2. Use a SSA Form 632 Request for Waiver of Overpayment.  These waivers are granted only when the client is without fault in causing the overpayment and where the adjustment or recovery would either defeat the purpose of title II of the Social Security Act or be against equity and good conscience.
  3. Appeal.

The appeal is the focus of this post.  It can be a short, written entry, or it can become a federal court case.  There are also intermediate levels of appeal.  The five levels of appeal are:

  1. Level 1 – Written appeal to the MSPRC;
  2. Level 2 – Written appeal to a Qualified Independent Contractor;
  3. Level 3 – Written and in-court appeal to an Administrative Law Judge;
  4. Level 4 – Medicare Appeals Council (MAC) review; and,
  5. Level 5 – Cause of action in the local federal district court.

Level 1 – Written Appeal to the MSPRC

The first level of appeal is a written appeal to the MSPRC.  This Medicare lien appeal should be a multiple page explanation of why the MSPRC erroneously included certain billing codes.  If necessary, medical documentation should be used to prove a code as unrelated.

Level 2 – Written Appeal to a Qualified Independent Contractor

This second level of appeal can be the same as the first – but to a different entity.  However, if the first appeal failed, you should reorganize and alter your arguments.  This level of appeal should include medical documentation, letters from treating doctors, etc.

Level 3 – Written/Video Conference Appeal to an Administrative Law Judge

The third level of appeal requires even more extensive preparation than the previous two levels.  Exhibits including medical records, letters from treating doctors, and even detailed explanations of why the ailments connected to certain ICD-9 codes cannot be related to the case.  Then, you and the client will go in front of an ALJ (via video-conference or teleconference) to argue the case.  A representative from Medicare may be  involved as well.  The in-person argument allows you, and your client to effectively convey your message.  This appeal is more likely to be successful if you have prepared well.

Level 4 – Medicare Appeal Council (MAC) Review

If you’ve made it to level 4, you probably haven’t done a good job.  This review is unlikely to succeed if the previous three levels have failed; and, that is all the more reason why the level 3 appeal is so important.  If the level 3 appeal isn’t a masterpiece, you are doing a disservice to your client.

Level 5 – Federal Court Case

You can file a cause of action in your local federal district court as a level 5 appeal.  However, like level 4, your chances of success are slim.  If you need lien resolution assistance, please contact LRS.  We are experts in all healthcare lien resolution including the multilevel appeal process.

Ryan J. Weiner
Co-Founder Lien Resolution Services
This Blog/Web Site is made available by the publisher for educational purposes only as well as to give you general information and a general understanding of the law, not to provide specific legal advice. By using this blog site you understand that there is no attorney client relationship between you and the Blog/Web Site publisher. The Blog/Web Site should not be used as a substitute for competent legal advice from a licensed professional attorney in your state.

About Ryan J. Weiner

Co-Founder of Lien Resolution Services, LLC, a national healthcare lien resolution firm. Our goal is to assist in the fair administration and resolution of healthcare liens on personal injury cases. Please visit our website for more information: www.lienresolutionusa.com.

2 comments on “Medicare Lien Appeals – The Five Levels

  1. […] So what does Bradley v. Sebelius mean for Medicare liens?  For one, challenging them might be getting easier.  However, the plaintiff only made it as far as the 11th Circuit because it exhausted all of it’s administrative remedies (see: The Five Levels of Medicare Appeals). […]

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