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Medicare expects providers to exercise care when billing and accepting payment. Medicare also expects that providers will promptly bring incorrect payments to the Medicare Administrative Contractor’s (MAC) attention.
The Centers for Medicare and Medicaid Services (CMS) requires documentation to support coverage and payment of services provided to Medicare beneficiaries. These requirements stem directly from Title XVIII of the Social Security Act (Act), Section 1833(e):
A provider or supplier (or their representative) can utilize the Medicare Appeals Process (Section 1869 of the Social Security Act and 42 CFR part 405 subpart I contain the procedures for conducting appeals of claims in Original Medicare (Medicare Part A and Part B)). However, in order for an appeal to be available, you must first file a claim and have that claim denied completely or partially. This is called the initial determination. An example of a partially denied claim could be that you coded a claim, and the Medicare Administrative Contractor (MAC) changed the coding and now you will be receiving less reimbursement. Alternatively, you could have submitted a claim, been paid, and then your claim is audited and then denied. This would usually allow you to utilize the appeals process as well. This document will examine the first three (3) levels of the appeals process as most providers and suppliers only utilize these levels. Utilizing a representative that understands the complex process is often in your best interest.
Engage Health, a nationwide leader in reimbursement technologies and solutions, welcomes Steven A. Greenspan JD, LLM to the role of Chief Strategy Officer. In this role, Steven will leverage his in-depth knowledge of healthcare regulatory compliance and the resulting challenges faced by providers and payors alike, to lead the enterprise strategic growth initiatives at Engage, including product management and solution development.
Engage Health, a nationwide leader in reimbursement technologies and solutions, is proud to announce the appointment of Dr. Robert Glenn as the new Chief Medical Officer.