Regulatory Compliance & Appeals
Master regulatory requirements and the Medicare appeals process
- Navigate the five-level Medicare appeals process effectively
- Understand False Claims Act, Stark Law, and compliance obligations
- Implement effective compliance program per OIG guidelines
- Manage self-reporting obligations and overpayment scenarios
- Challenge extrapolation methodology and statistical validity
Level 1: Redetermination (MAC)
Timeline: Request within 120 days of initial determination. MAC has 60 days to decide.
Process: MAC reviews its own decision. Submit additional documentation and written argument.
Success Rate: 10-15% (MAC rarely reverses itself)
Strategy: Present strongest clinical documentation and clear rebuttal. Set foundation for higher appeals.
Level 2: Reconsideration (QIC)
Timeline: Request within 180 days of Level 1 decision. QIC has 60 days to decide.
Process: Independent review by Qualified Independent Contractor. Can submit new evidence.
Success Rate: 20-30% (independent review improves odds)
Strategy: Present comprehensive clinical rationale. QIC is independent of MAC - fresh perspective.
Level 3: ALJ Hearing
Timeline: Request within 60 days of Level 2 decision. Hearing typically within 90 days.
Process: Administrative Law Judge hearing. Live testimony, witness examination, cross-examination.
Requirements: Amount in controversy ≥ $200 (adjusted annually)
Success Rate: 40-50% (highest success rate - can present full case)
Strategy: Present clinical experts, cross-examine MAC's position, demonstrate clinical appropriateness.
Level 4: Medicare Appeals Council
Timeline: Request within 60 days of ALJ decision. Council has 90 days to decide.
Process: Discretionary review - Council decides whether to review case. No hearing.
Success Rate: Variable (Council may decline review)
Strategy: Focus on legal/policy issues, not just clinical disagreement. Council reviews ALJ's legal reasoning.
Level 5: Federal District Court
Timeline: File within 60 days of Council decision.
Requirements: Amount in controversy ≥ $1,760 (adjusted annually)
Process: Federal court litigation. Requires legal counsel.
Strategy: Reserved for significant dollar amounts and important policy issues. Expensive and time-consuming.
False Claims Act (FCA)
Prohibits: Knowingly submitting false claims to Medicare
"Knowingly" means: (1) Actual knowledge, (2) Deliberate ignorance, (3) Reckless disregard
Penalties: $13,000-$27,000 per false claim + treble damages (3x overpayment)
IRF-PAI Application: Systematic upcoding, ignoring coding guidance, falsifying documentation
Key Point: "I didn't know" is not a defense if you deliberately avoided learning correct coding.
Stark Law (Physician Self-Referral)
Prohibits: Physician referrals to entities with which they have financial relationships
IRF-PAI Risk: Physician compensation tied to admissions, CMG levels, or tier coding
Compliance: Physician decisions must be independent of financial incentives
Warning: Bonuses based on facility revenue or coding outcomes violate Stark Law.
OIG Seven Elements of Compliance
1. Written Policies & Procedures
Comprehensive coding, billing, and compliance policies
2. Compliance Officer & Committee
Designated leader with authority and resources
3. Training & Education
Regular training for all staff involved in coding/billing
4. Effective Communication
Hotline, open-door policy, non-retaliation
5. Auditing & Monitoring
Regular internal audits, error tracking, trend analysis
6. Response to Violations
Investigation, corrective action, self-reporting when required
7. Enforcement & Discipline
Consistent discipline for violations, accountability
Self-Reporting Obligations
When to Self-Report:
- • Systematic overpayment identified (pattern of errors)
- • Overpayment exceeds $25,000 aggregate
- • Within 60 days of identification
- • Conduct comprehensive audit to determine full scope
- • Calculate exact overpayment amount
- • Submit repayment with self-disclosure
Failure to self-report systematic overpayments = False Claims Act violation
10
Questions
90%
Passing Score
~15
Minutes
Quiz Instructions:
- Answer all 10 questions to complete the quiz
- You must score 90% or higher to pass
- You can navigate between questions before submitting
- Review explanations for all questions after submission
- Retake the quiz as many times as needed to pass