Castle Rock Medical Group
Medicare Program Safeguard Contractor Consulting & Legal Services
Helping Providers Insure CMS Compliance & Benefits Integrity

PSC Audit Compliance & PSC Appeal Legal Services

Castle Rock Medical Group (a Jackson Davis HealthCare company) provides the nation's most efficient & effective professional services solution for the evaluation and submission of Medicare Program Safeguard Contractor (PSC) audit appeals.

CRMG's experienced Medicare consultants and clinical auditors team with the industry's leading health law firms and Medicare lawyers to provide a seamless consulting and legal services solution including - CMS clinical and billing case reviews, case review appeals summaries, required CMS documentation and submission of appeals starting with the initial stage of PSC appeals process.

In order to effectively evaluate and consider the merits of each PSC appeals case, it is critical that providers and their respective legal counsel have an in-depth understanding of CMS evidence-based standard of care practices, CMS clinical & documentation payment criteria and CMS directives related to each PSC audits focus area.  CRMG leads the nation in understanding, documenting and applying CMS payment criteria for cases being considered for PSC audits and PSC appeals.

PSC Appeals - Process & Overview

1)  Step 1 - CMS Criteria-Based Case Review

Castle Rock Medical Group physicians, nurses, billing compliance professionals and legal services staff will evaluate each denial / overpayment determination case and compare the underlying documentation to required CMS payment criteria.  CMS criteria-based case reviews includes the evaluation of underlying clinical considerations, supporting medical records documentation, CMS evidence-based payment criteria and estimated financial impact.

2)  Step 2 - Prepare PSC Appeals & CMS Criteria-Based Case Summary

Based upon the outcome of the CMS criteria-based case review, we prepare all medical records, required CMS supporting documentation and a PSC appeals criteria-based case summary to accompany the submission to the Medicare Administrative Contractor (MAC).

3)  Step 3 - Submit PSC Appeals & Required Documentation

Submit all required CMS documentation to the Medicare Administrative Contractor and coordinate with provider staff and selected legal counsel throughout the redetermination & reconsideration process (PSC appeals - stages 1 & 2).  PSC appeal will be filed within 30 days of denial in order to stop the recoupment process.

4)  Step 4 - Coordinate with Legal Counsel at Reconsideration

If the provider's appeal efforts are not initially successful in the redetermination stage, CRMG professionals will work collaboratively with select health law firms in each of the PSC regions to most effectively and aggressively challenge PSC audits recoupment throughout the remaining steps of the PSC appeals process.

5)  Step 5 - Provide CMS Regulatory & Clinical Expert Testimony

If the provider's appeal efforts are not initially successful during the initial 2 stages, CRMG can provide a full range of expert regulatory & clinical testimony in support of a provider's adherence to CMS payment criteria at ALJ hearings and or subsequent judicial proceedings.

To speak with our experienced Medicare consultants, clinical auditors or Medicare lawyers - or for questions regarding Medicare PSC appeals, CMS billing and clinical case reviews, proactive PSC audit medical assessments or recommended PSC appeals lawyers - please contact us directly at (303) 586-5003 or appeals@pscaudits.com.
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The following information MUST be included with your request for all appeal levels:

Beneficiary name
Medicare Health Insurance Claim (HIC) Number
Specific service(s) and/or item(s) for which the redetermination / reconsideration is being requested
Specific date(s) of the service; and
Name and signature of the provider or the representative of the provider

First Level – Redetermination (Medicare Administrative Contractor)

Claim denials or overpayments must be initially reviewed (appealed) to the appropriate Medicare Administrative Contractor (MAC) by requesting a redetermination of the claim within 120 days of the PSCs initial decision.  Medicare Administrative Contractors are required to respond to a provider’s request for redetermination within 60 days of receipt.

Second Level – Reconsideration (Qualified Independent Contractor)

If a provider is dissatisfied with the outcome of the Level 1 appeal or redetermination process, a request for “reconsideration” may be filed with the appropriate Qualified Independent Contractor (QIC) within 180 days of the redetermination.  Requests for reconsideration are required to be processed within 60 days by the QIC.

Third Level – Administrative Law Judge Hearing

If a provider is not satisfied with Level 2 and the result of reconsideration, a hearing before an Administrative Law Judge (ALJ) can be requested.  The amount in controversy must be a minimum of $120 and requests for a hearing from an ALJ must be received within 60 days of the provider’s notice of the reconsideration outcome.

Fourth Level – Medicare Appeals Council (MAC)

If the Level 3 appeal and decision by the ALJ is considered unfavorable by the provider, a fourth level appeal request may be filed with the Departmental Appeals Board (DAB) / Medicare Appeals Council (MAC).  Requests for a MAC review must be filed within 60 days of receipt of the ALJ’s decision.  The MAC must subsequently issue a determination within 90 days of the review.

Fifth Level – U.S. District Court Review

If the Level 4 decision of the MAC is deemed unfavorable to the provider, the final step in the appeals process is to file suit in U.S. District Court.  Requests must be filed within 60 days of the MACs decision and the amount in controversy must be at least $1,180.

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CMS Transmittal 141 - Limitation on the Recoupment of Medicare PSC Audit Overpayment Determinations

CMS Transmittal 141 specifically addresses a diverse range of Medicare appeals issues and discusses revisions to the Medicare PSC appeals process.   Probably the most important aspect of Transmittal 141 is the timing of recoupment by CMS for overpayment determinations by contracted recovery auditors.

In summary, time frames relating to the filing of appeals during the first 2 steps of the PSC appeals process have not changed (i.e. 120 days to file for redetermination and 180 days to file for reconsideration).  However, in order to stop the automated recoupment of overpayments, providers MUST file PSC appeals within 30 days for redetermination and within 60 days for reconsideration.