"This book is about how to successfully fight for the payment of medically reasonable and necessary services when Medicare erroneously denies payment, or when Medicare erroneously demands a repayment of overpayment"--

A Practical Guide to Medicare Appeals describes the steps necessary to successfully resolve appeals of all types of Medicare determinations. Co-authored by a CMS hearing officer and a private practitioner with years of Medicare appeals experience, this book will walk practitioners through every step of the very confusing and sometimes self-contradictory rules so that appeals can be decided on their merits rather than barred for procedural rules violations.

An appeal is the action you take if you disagree with a coverage or payment decision made by Medicare, your Medicare Advantage Plan (like an HMO or PPO), other Medicare health plan, or your Medicare Prescription Drug Plan. You have the right to appeal if Medicare, your Medicare health plan, or your Medicare Prescription Drug Plan denies one of these: A request for a health care service, supply, item, or prescription drug that you think you should be able to get; A request for payment of a health care service, supply, item, or prescription drug you already got; A request to change the amount you must pay for a health care service, supply, item, or prescription drug. You can also appeal if Medicare or your plan stops providing or paying for all or part of a health care service, supply, item, or prescription drug you think you still need. This publication has important information about: How to file an appeal if you have Original Medicare; How to file an appeal if you have a Medicare Advantage Plan or other Medicare health plan; How to file an appeal if you have Medicare prescription drug coverage; Where to get help with your questions. Also available in Spanish.

This book provides an overview of the Medicare FFS audit and Medicare appeals environment. It starts with an overview of the various CMS contractors performing claims review (including post-payment and pre-payment auditing activities). Then the Medicare Part A and Part B appeals process is examined. Finally, appeal strategies are set forth along with legal challenges applicable to Part A and Part B unfavorable claims determinations, with which attorneys should familiarize themselves when representing a health care entity subject to audit. A list of resources and references is included at the conclusion of this book.

Did you know the time for your healthcare provider's Medicare hearing has skyrocketed from the Congressionally mandated three months to over three years? Did you want to know why the good ship OMHA has been swamped? Did you know the crisis affects all of us, and that we must act now before the 2016 budget is passed? Would it surprise you that the bill pending in Congress to address the backlog of over 600,000 cases - the AFIRM (Audit & Appeal Fairness, Integrity and Reforms in Medicare Act) is not a panacea? Do you want straight talk from a former ALJ about what's going on at Medicare (CMS) and in the Office of the Chief Judge? Can you imagine a system that works for us, not for ""them?"" A portion of the proceeds are donated to worthy causes, such as the Center for Medicare Advocacy. Note: You can buy a book without setting up a Lulu account. Thank you.