Wiki Third Level Appeal (ALJ)


Lincoln, IL
Best answers
Any tips for this hearing? I just mailed my request for ALJ yesterday. I rec'd an "unfavorable" decision from QIC who in my opinion didn't even read what I was appealing. We had incorrectly billed a bilateral hip replacement done in the same operating session by two different physicians. Prior to billing this I contacted Medicare and was told to bill the same way they recommend billing bilateral knees in same session by two physicians using modifiers 50 and 62. I have documentation of conversations with 2 different people from WPS telling me this was correct. Come to find out it shouldn't have been billed that way after I spoke with someone teaching a WPS Medicare Seminar, therefore, had to start to "appeal process" I am so frustrated over this and cannot understand why QIC delivered an unfavorable decision stating it didn't support co-surgeons even though I clearly explained the situation to them!

Hello Beev,

It's been a long time since I was directly invovled with appeals but I was successful back in the day! One of the big changes I made in our process was requesting a telephone hearing at that second appeal level, instead of sending in the documentation again with an explanation letter. Talking directly with the hearing officer was a big benefit, and I was luck enough to get the same officer almost every time! We developed a very good working relationship and was able to share learned information that helped both of us. (He understood where I was coming from, and I understood some of the "why" a little better). I did request and participate in an A L J hearing. I believe this was by telephone also but I can't remember for sure as it has been a long time ago. It was tougher than the hearings I was familiar with, and I think at least one outcome was positive, but I cannot remember this for sure.

Sorry I can't be more helpful. I do recommend moving ahead if you believe in your documentation.

Good luck!