Effective October 27, 2014, the Medicare Program Integrity Manual (“Manual”) will require Medicare Administrative Contractors (“MACs”) to participate in administrative hearings concerning medical review decisions. According to the Centers for Medicare & Medicaid Services (“CMS”), the purpose of the revised language is to notify MACs of their obligation to support medical review decisions, either as a participant or a party at the Administrative Law Judge (“ALJ”) hearing level. The new Manual requirements will likely prompt significant changes to ALJ hearings, potentially making the hearings more adversarial.

The new Manual provisions will require MACs to assign a physician to participate or become a party at the ALJ hearings. The participating physician must be a Certified Medical Director, a MAC employed physician or both.

An important element to any ALJ hearing is the Notice of Opportunity. The new Manual revisions require notification of hearing requests to MACs, as well as a process for MAC physicians to select the cases in which to participate. Factors to determine MAC physician participation include policy implications, monetary amount, source of the denial, program integrity matters, and whether the issue is reoccurring at the ALJ level.

In light of this MAC physician involvement, providers have an increased obligation to ensure that documentation supporting services provided is part of the redetermination and reconsideration record. Failure to have such information in the record may create greater difficulties in obtaining a successful appeal.