Medicare Appeals for Healthcare Providers: Understanding the Appeals Process and the Impact of the Backlog

Maximizing Reimbursement Performance and Mitigating Risk

Recording of a 90-minute CLE webinar with Q&A

Conducted on Thursday, February 5, 2015

Recorded event now available

or call 1-800-926-7926
Course Materials

This CLE course will provide healthcare counsel with a review of the Medicare Part B appeals process, the impact of the backlog, and the effect of CMS’ 68% solution. The panel will drill down into the issues on which the Medicare Administrative Contractors (MACs) are focusing. The panel will provide guidance for compliance, offer best practices to improve reimbursement performance, and outline approaches to mitigate risk.


Healthcare providers receive claim denials or overpayment demands as a result of Medicare Part B audits. While these denials can be appealed, often with success, healthcare counsel must fully understand and be able to navigate the Medicare appeals process to protect clients from incorrect assessments and penalties. Those appealing Medicare denials must strictly comply with the appeals timelines and CMS offers limited exceptions if deadlines are missed. Healthcare counsel must be prepared to navigate the five levels of review to maximize the reimbursement to the healthcare provider.

Significant activity from the various Medicare Administrative Contractors (MACs), Recovery Audit Contractors (RACs), and Zone Program Integrity Contractors (ZPICs) has dramatically increased the volume of Medicare claims denials. The Office of Medicare Hearings and Appeals (OMHA) has committed significant time and resources to examining the root causes of the backlog and potential solutions for relieving the burden of the backlog on Medicare providers. However, for the time being, the backlog has significant legal and financial implications of which counsel must be aware.

Listen as our panel reviews the Medicare Part B appeals process, the impact of the backlog, and the effect of CMS’ 68% solution. The panel will also discuss the MACs and the issues on which they are focusing. The panel will provide guidance for compliance, offering best practices to improve reimbursement performance and mitigate risk.



  1. Understanding the Medicare Part B appeals process
    1. The Medicare Part B appeals process
    2. The appeals backlog
    3. OMHA’s appellant forums and process improvements in the works
    4. CMS’ 68% solution
  2. A report “From the Trenches”
    1. Get to know the MACs
    2. Issues that MACs are most focused on
    3. A “Real” perspective on the appeals backlog
  3. Focus on compliance—solution or merely a stopgap to appeals?
    1. Overview of corporate compliance
    2. Compliance efforts to specifically improve reimbursement performance and mitigate risk
    3. Risks of noncompliant behavior


The panel will review these and other important issues:

  • The levels of review and the timelines with which providers must comply
  • The types of claim denials providers most often encounter and why
  • Best practices to improve healthcare providers’ internal compliance efforts related to reimbursement and auditing processes


Stephanie Greene
Stephanie Greene
Chief Consulting Officer

Ms. Greene heads up the Auditing and Consulting Division and counsels clients in billing audits and appeals, as well as...  |  Read More

Amy F. Lerman
Amy F. Lerman

Epstein Becker & Green

Ms. Lerman focuses her practice on a variety of regulatory and transactional health care matters, including corporate...  |  Read More

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