The appeals process is a critical component of health care compliance, ensuring that denied claims are appropriately challenged and reconsidered. When providers and health care organizations receive claim denials, they often require skilled professionals to navigate the appeals process. In these cases, auditors play a crucial role, serving as subject matter experts, strategists, and compliance advocates.
Understanding the Appeals Process
Before diving into the auditor’s role, it’s important to understand the structure of the appeals process. When a provider or health care organization disagrees with a claim denial—whether from a commercial payor, Medicare, or Medicaid—they have the right to appeal.
For Medicare claims, the appeal process consists of five levels:
- Redetermination: A request for the Medicare Administrative Contractor (MAC) to review the denial.
- Reconsideration: A review by a Qualified Independent Contractor (QIC).
- Administrative Law Judge (ALJ) Hearing: A more formal appeal in front of an ALJ.
- Medicare Appeals Council Review: A review by the Departmental Appeals Board.
- Judicial Review: If all previous levels are unsuccessful, a case can be taken to federal court.
