Medicare Payer Denials

Similar to Medicaid patients, Medicare enrollees may have their benefits administered by a managed care organization, through Medicare Advantage (Part C), or by a contractor operating under the traditional Medicare program. Successfully appealing Medicare denials requires an understanding of the different appeal protocols and denial reasons for traditional Medicare and Medicare Advantage payers.

At HLS, we apply our understanding of technical and medical necessity denials to appeal Medicare Advantage denials while relying on our knowledge of CMS coding guidance to appeal traditional Medicare denials. Our attorneys have successfully defended clients against RAC and OIG audits on the redetermination and reconsideration levels of appeal – thus avoiding the need for time-consuming hearings and judicial reviews – although we are prepared to go through all five levels of appeal when warranted.