Lose Your Medicare Appeal at Reconsideration? Don’t Throw in the Towel Just Yet — Consider the Consequences and Your Options.
(June 18, 2011): As a review of the last several quarters of Medicare appeals statistics reflects, an overwhelming percentage of Medicare providers appealing alleged overpayments through the Medicare administrative appeals process have chosen to “throw in the towel,” so to speak, when they have lost at the reconsideration level. As you will recall, at the reconsideration level, Medicare claims are assessed by a Qualified Independent Contractor (QIC) selected by the Centers for Medicare and Medicaid Services (CMS) to hear the second level of administrative appeals. According to statistics kept by Q2 Administrators, the contractor selected to serve as the Administrative QIC ...
Are Medicare ALJ’s Truly Independent Fact Finders, Free From the Informal Pressures of CMS and its ZPIC / PSC / RAC / QIC Contractors?
(February 19, 2011): Over the years, we have represented a wide variety of health care providers in the administrative appeals process. Our duties have regularly included representation before Administrative Law Judges (ALJs) presiding out of the Western, Southern, Midwestern and Mid-Atlantic Field Offices of the Office of Medicare Hearings and Appeals. (OMHA). In the course of our work, we have routinely been asked by our health care provider clients for our opinion regarding the “independence” of ALJs from the pressures exerted by the Centers for Medicare and Medicaid Services (CMS) and its contractors (including, but not limited to the Qualified Independent ...
Be Prepared — ZPIC, PSC and QIC Representatives Are Increasing their Participation in Appeal Hearings, Personally Presenting Their Rationale for Denying Your Medicare Claims to the ALJ.
(February 12, 2011): Over the last year, we have noted an important trend when representing Medicare providers in post-payment overpayment cases at the Administrative Law Judge (ALJ) level of appeal. Medicare contractors are actively attending and participating in many ALJ hearings. The virtual "Courtroom" where ALJ hearings are typically held (most ALJ hearings are now held by teleconference or video-teleconference -- few are conducted in person) are no longer attended by only a provider, its attorney and the Judge. Instead, it is now relatively crowded, requiring the scheduling of experts and the testimony of various clinical specialists -- representing not only the provider, but also one or more ...
Keeping an Eye on Medicare’s AdQIC:
(December 29, 2010): At the outset, it is important to keep in mind that the following observations are merely our opinion, nothing more. These observations are based on our experiences dealing with health care provider Medicare overpayments and alleged false claims, over many years. Many health care providers are familiar with the revised administrative appeals process for contesting denied Medicare claims. In exercising their appeal rights, many providers (or their legal counsel) have appealed denied claims through the second level of appeal, submitting their claims and arguments in support of payment to the Qualified Independent Contractor (QIC) responsible for hearing ...
Recoupment, Extended Repayment and Appeal Strategies in “Big-Box” Cases — How Your Decisions at Earlier Levels of Appeal can Adversely Affect Your Case at the ALJ Level of Appeal
(December 3, 2010): In recent years, Medicare Administrative Contractors (MACs) have become much more likely to initiate recoupment of alleged overpayments in connection with post-payment audits as soon as they are permitted to do so. The purpose of this article is to examine steps that a health care provider should consider when weighing its repayment and appeal options in a post-payment audit. Recoupment considerations when filing for redetermination appeal. CMS’ current recoupment rules effectively vitiate the ability of a provider to use the 120-day period to prepare their case before filing for redetermination appeal. As the limitation on recoupment rules are currently applied, ...
CMS Contractors are Turning Up the Heat – Providers Around the Country are Having to Defend Favorable Decisions by an Administrative Law Judge
(September 1, 2010): Introduction: As previously discussed, after representing health care providers for many years in administrative hearings, involving well over 10,000 Medicare claims this year alone, it has been our experience that Administrative Law Judges (ALJs) remain a provider’s single best opportunity to present its legal, regulatory and factual arguments in support of payment. While there are no guarantees, the ALJs we have practiced before have been attentive, knowledgeable, willing to listen to the provider’s viewpoint, and perhaps most importantly, FAIR. The Process: Once a request for an ALJ hearing is filed, the Court generally takes one of three actions. It ...
Health Data Insights Begins Medical Necessity Reviews
(August 30, 2010): Introduction: Health Data Insights (HDI), the Centers for Medicare & Medicaid Services (CMS) Recovery Audit Contractor (RAC) responsible for auditing health care providers in Region D, has announced it will immediately begin reviews on previously approved projects which involve the medical necessity of selected inpatient DRG payments. A complete list of the medical necessity “issues” currently being examined by HDI can be found on its Website. Scope of Responsibility: RACs, such as HDI, contract with the CMS to perform post-payment reviews of Medicare claims to find overpayments (and theoretically, underpayments in return for a percentage (from 9 percent to ...
Look at RACs — Part III: What Should Physicians and other Medicare Providers Know about Appeals and Recoupment?
(July 2, 2010): CMS’ Recovery Audit Contractor (RAC) program is now permanent and nationwide. As we discussed in Part I of this series, while small providers were largely ignored during the demonstration program, physicians, home health, hospice, and durable medical equipment (DME) suppliers should be on the lookout for increased attention. In Part II, we discussed some ways providers can prepare for and respond to an audit request. In this Part III, we will discuss a provider’s appeal options in the event that a RAC identifies an alleged overpayment as a result of its audit. It is important to remember that ...
A Look at RACs — Part II: How Should Physicians and Other Providers Respond to a RAC Audit?
(June 28, 2010): In Part I of this series, we reacquainted you with the design and purpose of the now permanent Recovery Audit Contractor (RAC) Program. Although RACs largely focused on inpatient care during CMS’ demonstration program, RACs are a real threat to small providers that don’t have the intensive compliance programs in place that most hospitals do. In this Part II, we will look at how physicians, home health, hospice, and durable medical equipment (DME) suppliers can prepare for and respond to RAC audits. Even if no demands are issued, the RAC audit process exposes providers to substantial risks and ...
You’ve got to be kidding. . . more Medicare audits on the way?
(March 11, 2010): According to the White House, President Obama has announced that he intends to back bipartisan plans to stamp out waste in government-run medical programs for the elderly and needy. The White House said the new effort to root out improper payments in the Medicare and Medicaid programs could double taxpayer savings over the next three years to at least $2 billion. "We cannot afford nor should we tolerate this waste of taxpayer dollars," the White House said. The government believes that approximately $54 billion was lost through improper Medicare and Medicaid payments in 2009. Medicare is the government-run program ...
ALJ Appeal
Lose Your Medicare Appeal at Reconsideration? Don’t Throw in the Towel Just Yet — Consider the Consequences and Your Options.(June 18, 2011): As a review of the last several quarters of Medicare appeals statistics...
Are Medicare ALJ’s Truly Independent Fact Finders, Free From the Informal Pressures of CMS and its ZPIC / PSC / RAC / QIC Contractors?(February 19, 2011): Over the years, we have represented a wide variety of health...
Be Prepared — ZPIC, PSC and QIC Representatives Are Increasing their Participation in Appeal Hearings, Personally Presenting Their Rationale for Denying Your Medicare Claims to the ALJ.(February 12, 2011): Over the last year, we have noted an important trend when...
Recoupment, Extended Repayment and Appeal Strategies in “Big-Box” Cases — How Your Decisions at Earlier Levels of Appeal can Adversely Affect Your Case at the ALJ Level of Appeal(December 3, 2010): In recent years, Medicare Administrative Contractors (MACs)...
National Coverage Determination (NCD) and Local Coverage Determination (LCD) Guidance – How will an ALJ view these coverage guidelines when the Court is assessing whether my Medicare claims should be paid?(February 1, 2010): When treating patients, it is not uncommon for a physician...
Read More Posts From This CategoryGuidance
Keeping an Eye on Medicare’s AdQIC:(December 29, 2010): At the outset, it is important to keep in mind that the following...
CMS Contractors are Turning Up the Heat – Providers Around the Country are Having to Defend Favorable Decisions by an Administrative Law Judge(September 1, 2010): Introduction: As previously discussed, after representing...
Health Data Insights Begins Medical Necessity Reviews(August 30, 2010): Introduction: Health Data Insights (HDI), the Centers for Medicare...
Hang on tight — 2010 could be rough . . .(March 1, 2010): The number of auditors, reviewers, investigators and prosecutors...
Read More Posts From This CategoryMedicare Audits
Look at RACs — Part III: What Should Physicians and other Medicare Providers Know about Appeals and Recoupment?(July 2, 2010): CMS’ Recovery Audit Contractor (RAC) program is now permanent and nationwide. As we discussed in Part I of this series, while small providers were largely ignored during the demonstration program, physicians, home health, hospice, and durable medical equipment (DME) suppliers should be on the lookout for increased attention. ... [Read more of this review]
A Look at RACs — Part II: How Should Physicians and Other Providers Respond to a RAC Audit?(June 28, 2010): In Part I of this series, we reacquainted you with the design and purpose of the now permanent Recovery Audit Contractor (RAC) Program. Although RACs largely focused on inpatient care during CMS’ demonstration program, RACs are a real threat to small providers that don’t have the intensive compliance programs in place that most... [Read more of this review]
A Look at RACs — Part I: What Do Physicians, Home Health, Hospice, and DME Providers Need to Know?(June 25, 2010): The purpose of this series of articles is to assess the Recovery Audit Contractor (RAC) Program from the perspective of physicians, home health, hospice, durable medical equipment (DME) providers, and other relatively small Medicare providers. As many non-hospital providers will acknowledge, early cries of wolf by law firms and consultants... [Read more of this review]
You’ve got to be kidding. . . more Medicare audits on the way?(March 11, 2010): According to the White House, President Obama has announced that he intends to back bipartisan plans to stamp out waste in government-run medical programs for the elderly and needy. The White House said the new effort to root out improper payments in the Medicare and Medicaid programs could double taxpayer savings over the next... [Read more of this review]
Final Rule Outlining Recoupment Limitations and the Impact on Ongoing Medicare Overpayment Appeals Cases(February 1, 2010): Last September, the Centers for Medicare and Medicaid Services (CMS) published its Final Rule addressing limitations on the recoupment of alleged overpayments by its Medicare contractors (e.g. Medicare Administrative Contractors and Qualified Independent Contractors). This Final Rule finalizes how Medicare contractors are to... [Read more of this review]
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