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  1. #1
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    Default Do Social Security Regulations Apply to Appeals of Medicare Denials

    I am a physician working on an appeal of an ALJ decision concerning Medicare Payment denial. I am appealing his decision to the Medicare Appeals Council.

    1). Good news: there are a lot of cases concerning principles governing ALJ's when they determine Soc Sec Disability claims. These cases involve exactly the same chart notes, medical principles, types of cases as the Medicare Payment denial cases. There are a great many of these available to review.

    2). Bad news: there are relatively very few cases concerning principles governing ALJ's determinations in Medicare Payment denial appeals, because payment denial has only recently become popular and "vogue" under the present administration........

    I need to be able to apply the same principles, decisions, rulings, etc used in the SSD cases, to Medicare payment denial cases. They both utilize ALJ's, both are part of the Social Security Administration, etc. Appeals from Medicare ALJ's go to the Medicare Appeals Council. Don't know where the others go. The dudes on Westlaw tried but really didn't help much. Can anyone here please point me in the right direction?

  2. #2
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    Default Re: Do Social Security Regulations Apply to Appeals of Medicare Denials

    You want to know the next level of appeal after the denial of a Medicare claim by an ALJ?

  3. #3
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    Default Re: Do Social Security Regulations Apply to Appeals of Medicare Denials

    Hi, Mr. Knowitall ! No, I know that from the ALJ, appeals go to the MAC. I want to know if the same administrative rulings, laws, opinions, applied to the medical cases in ALJ Soc Sec Disability determinations can be applied to ALJ Medicare Payment Denial determinations. Both consider almost identical cases, same med records, same clinical scenarios, etc. It is just that there isn't much case law on the Medicare Payment Denials because that hasn't been going on as long as ALJ's hearing Soc Sec Disability cases. I know this is an obtuse question. Sorry. Maybe an example: If I find a SSD case that says "the ALJ erred in misquoting the diagnosis list," and I have a Medicare case in which the ALJ totally misstates the diagnosis list, can I say he erred on the basis of the SSD case in which the ALJ similarly erred? Thank you sooooo much!

  4. #4
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    Default Re: Do Social Security Regulations Apply to Appeals of Medicare Denials

    Medicare and Social Security Disability are two (or three, given that Social Security encompasses both SSI and SSD) separate programs, with different criteria for eligibility. The fact that you are eligible for benefits under one program does not automatically mean that you are eligible for benefits under another. So if your question is about eligibility for benefits, not courts or court procedure, then you would need to look at the separate eligibility standards for each program and for the benefit at issue.

  5. #5
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    Default Re: Do Social Security Regulations Apply to Appeals of Medicare Denials

    determinations of eligibility for disability benefits have nothing at all to do with billing disputes and case law from one would be no guide whatsoever for the other.

    Department of Health and Human Services has hearing decisions posted

  6. #6
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    Default Re: Do Social Security Regulations Apply to Appeals of Medicare Denials


  7. #7
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    Default Re: Do Social Security Regulations Apply to Appeals of Medicare Denials

    My question is: if an ALJ can be faulted for disregarding the medical record in an SSD case, can an ALJ be similarly faulted for disregarding the medical record in exactly the same way in a Medicare Pmt denial case?

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    thank you. I will try that link.

  8. #8
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    Default Re: Do Social Security Regulations Apply to Appeals of Medicare Denials

    It will depend upon (a) the facts, (b) the issues, and (c) the standard of review.

  9. #9
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    Default Re: Do Social Security Regulations Apply to Appeals of Medicare Denials

    Hi, Lehk. That is an incomplete listing of their decisions. This document says that "all" of the decisions since 2010 are posted on "Westlaw". I paid an arm and a leg to get access to that and I just can find any useful or applicable cases.

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    Mr. KIA,
    I understand what you are saying. I could give an example, but it would be kind of longish, and I don't know if one can do that here....

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    Quote Quoting flyingron
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    This seems more like how to go about appealing if you are a beneficiary who needs to. thanks, though

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    Let me explain again, to clarify:

    I have a Medicare Payment Denial case heard by the ALJ. He ignored the medical record and lengthy documentation we gave that pt had x,y,z diagnoses, was gravely ill, the order of priority of her illnesses, the reason for hospital admission.

    Among Medicare Appeals Case cases, I can't find any analogous cases decisions of which to apply to this case.

    Among SSD cases, I can find cases in which the ALJ ignored the medical record and lengthy documentation given by the expert witness that pt had x,y,z diagnoses, ignored that the patient was gravely ill, ignored and misstated the reason for hospital admission.

    So, for the reasons that the ALJ decision was overturned concerning these errors, can one maintain that the ALJ decision in a Medicare case be overturned for the same administrative principles?

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