With more than 60 million beneficiaries, the Centers for Medicare & Medicaid Services (CMS) processes more than 1 billion Medicare Part A and Part B Fee-for-Service (FFS) claims each year. The vast majority of these claims are processed without undergoing claims review, creating vulnerability for the Medicare Trust Funds. Authorized by various legislative actions, CMS has contracted with claims review entities to perform post-payment and pre-payment claims review. Health care providers and suppliers that have received a Medicare FFS claim denial or overpayment determination may appeal the initial determination through a five-stage uniform Part A and Part B appeals process.


This book provides an overview of the Medicare FFS audit and Medicare appeals environment. It starts with an overview of the various CMS contractors performing claims review (including post-payment and pre-payment auditing activities). Then the Medicare Part A and Part B appeals process is examined. Finally, appeal strategies are set forth along with legal challenges applicable to Part A and Part B unfavorable claims determinations, with which attorneys should familiarize themselves when representing a health care entity subject to audit. A list of resources and references is included at the conclusion of this book.