5 Performance Strategies for the Medicare Appeals Process

With the Medicare appeals process, things are slightly different than with medical malpractice cases. The attorneys are hired by the hospital corporation. Sometimes they’re well-versed in health conditions and sometimes not. Use these five performance strategies as a Certified Legal Nurse Consultant to help attorneys perform better. The impact will be a positive one for the hospital client who hires you.

1. Ask for assignment of an attorney on the same day that the administrative law judge (ALJ) hearing appointment has been received by the hospital. I call the corporate legal office and email a copy of the hearing notice to them. The sooner this is done, the easier it is to shift around the schedules of the attorneys and assign one to your case.
2. Identify the documents the attorney wants. Attorneys almost never want the patient’s complete medical record. All medical records related to the exhibits are needed. Any additional documentation related to a pivotal medical condition or to support the exhibits that were submitted with the ALJ hearing request will also be needed. If your attorney doesn’t understand all medical conditions and their relation to each other, educating the attorney will help him do the same thing for the presiding ALJ in the hearing.
3. Develop and maintain a case facts and observations document. This is the list of strengths and weaknesses of the case and why they are so designated. For purposes of Medicare appeals, the form is combined with details such as the date of the claims denial, dates of successive appeals and denials, date of the hearing and name of the ALJ. Usually, the attorney wants a copy.
4. In documents you send to the attorney, include the word-for-word, “findings,” section from every successive denial and the name of the contractor company who issued it. Occasionally, contractors will step on their own toes and indicate a bias against age or condition of the Medicare beneficiary. That’s illegal and our attorneys love when it appears. It nearly always guarantees a win.
5. If there are any glaring weaknesses to the case, always ask the attorney if he plans to walk around it or to address it head-on in the hearing to remove that weapon from the ALJ’s hand or from the hand of the opposing testifying witness, or both. It’s good to know this in advance so that your own witnesses are ready for it and are not blind-sided.

Anytime a Medicare appeals case can proceed with a timely and flawless delivery, it makes the ALJ happy, often results in a favorable decision, and reflects well on your attorney and makes him want to work with you again.

Guest Blogger Profile

Camille Joyner, RN, BSN, CCM, CLNC, CEO and co-owner of C. Joyner and Associates, LLC consults and manages Medicare Part A appeals for acute general rehabilitation hospitals. She also consults for records review/audit for physician medical pertinence and in non-Medicare negligence cases.

P.S. Comment here to share your experience working with attorneys on Medicare appeals cases.