For physicians to challenge denied payments in the higher avenues of Medicare’s appeals process, the amount in controversy in the underlying dispute must now meet higher minimum thresholds in 2026 compared to previous years.
“The way the system exists already, it disincentivizes small practices to pursue this,” said Tina Philip, DO, vice chair of the Texas Medical Association’s Council on Socioeconomics. “It’s hard for independent practices, and particularly for primary care practices, because most of us won’t meet the thresholds.”
Per the Centers for Medicare & Medicaid Services (CMS), there are five levels in the Medicare Part A and Part B appeals process. The levels are:
- First level of appeal: Redetermination by a Medicare administrative contractor;
- Second level: Reconsideration by a qualified independent contractor;
- Third level: Decision by the Office of Medicare Hearings and Appeals (OMHA);
- Fourth level: Review by the Medicare Appeals Council (MAC); and
- Fifth level: Judicial review in federal district court.
After exhausting these processes, physicians generally have two options for seeking legal review: review by an administrative law judge (ALJ) or expedited access to judicial review (EAJR). (If a dispute is eligible for EAJR, the physician would submit a request for that review after the second level of appeal.)
Eligibility for both types of review requires the amount in controversy in the underlying disputes to meet a certain dollar threshold, whereas Medicare’s initial processes do not. The amount of money at stake is statutorily subject to annual adjustments based on the medical care component of the consumer price index.
Between 2022 and 2026, that threshold has risen by a little more than 11%. In 2022, the minimum threshold for an ALJ hearing was $180, and in 2025, it increased to $190; it’s now risen to $200 for 2026. Similarly, the judicial review threshold was $1,760 in 2022 and $1,900 in 2025; for 2026, it’s up to $1,960.
Dr. Philip, a Round Rock family physician, notes while Medicare payment for many primary care services wouldn’t rise to the minimum amount required, some specialists – especially those seeking payment for certain procedures surpassing the threshold – might determine it’s worth engaging in the process.
For Medicare Advantage, CMS notes an initial appeal determination is made by the insurance company issuing the plan, which also handles what CMS terms the Level 1 Appeal. Beyond that, a physician can appeal to Maximus, a Part C Independent Review Entity (IRE), and physicians can appeal an IRE’s adverse decision by requesting an ALJ hearing.
Physicians who don’t want to attend a hearing have the option of filing a waiver of right to an ALJ hearing (Form OMHA-104). However, an ALJ may determine it’s necessary to hold a hearing even if all parties involved have waived their rights to a hearing.
Additionally, if the ALJ renders an unfavorable decision, the physician can appeal that decision to the MAC. If the MAC renders a decision that the physician finds unfavorable, the physician can file an action in federal district court within 60 days of that decision.
“If the ALJ’s decision is unfavorable, the decision will contain information needed to file a request for review by the Medicare Appeals Council,” CMS added in its online guidance.
Forms for the appeals are available through the U.S. Department of Health and Human Services website.
TMA can assist physicians with payment disputes through its Physician Payment Resource Center, and offers tips, tools, and resources pertaining to billing, coding, and claims.
Phil West
Associate Editor
(512) 370-1394
phil.west[at]texmed[dot]org
Phil West is a writer and editor whose publications include the Los Angeles Times, Seattle Times, Austin American-Statesman, and San Antonio Express-News. He earned a BA in journalism from the University of Washington and an MFA from the University of Texas at Austin’s James A. Michener Center for Writers. He lives in Austin with his wife, children, and a trio of free-spirited dogs.