A New Compliance Challenge: Appealing Medicare Claims Denials

Thomas Herrmann | May 2013

Compliance with all the legal, regulatory, and program requirements relating to provider/supplier participation in the Medicare program is an ongoing challenge for health care providers and suppliers. Among the issues faced is keeping current in understanding and complying with program requirements and ensuring timely and complete Medicare payments for items and services furnished to program beneficiaries. Increasingly, provider and supplier claims are being denied or challenged by Medicare administrative contractors (MACs) or payment safeguard contractors, such as recovery audit contractors (RACs) and zone program integrity contractors (ZPICs). To respond appropriately, providers and suppliers need to understand and use the Medicare claims appeals process to challenge improper denials of Medicare payments.

About the Author

Thomas Herrmann advises health care clients on compliance and regulatory matters, with a focus on development and management of effective health care compliance programs. Mr. Herrmann is a recognized expert on issues related to the federal Anti-Kickback Statute, Stark Law and the False Claims Act.