MACs to Participate in ALJ Hearings

on Monday, 16 July 2012. All News Items | MAC Reviews

Cahaba GBA, the Medicare Administrative Contractor (MAC) for Jurisdiction 10 (Alabama, Georgia, and Tennessee) announced at the July meeting of the Alabama Hospital Association Revenue Integrity Committee that MACs may now participate in Administrative Law Judge (ALJ) hearings. The ALJ hearings are the third level of the Medicare appeals process for fee-for-service providers and have historically had a high percentage of reversals of denials. Dr. McKinney, the Medical Director for Cahaba, stated that the MACs will not participate in all ALJ hearings, but may participate in select ALJ hearings, such as those involving high-dollar claims. It is also noted that the CMS webpage for ALJ Appeals (last updated March 20, 2012) states that “CMS or its contractors may become a party to, or participate in, an ALJ hearing after notifying all parties to the hearing.”

Dr. McKinney reported the results of a pilot program involving MAC representation in the ALJ hearing process. Prior to the involvement of the MAC, the ALJ hearing overturn rate was 50-60%. After a MAC representative began participating in the ALJ hearing, the overturn rate decreased to 20%.

Providers should take note of this new process and realize the impact this may have on the outcome of ALJ hearings. It is likely that MAC participation will not only affect the hearings in which the MAC participates directly, but will also provide information / education that the Administrative Law Judge may consider in other appeals of the same nature, even those without direct MAC participation.

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