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MEDICARE APPEALS AND MEDICAID APPEALS

WE HANDLE ALL TYPES OF MEDICARE APPEALS AND MEDICAID APPEALS FOR HEALTH CARE PROVIDERS

 

We have over 15 years of experience representing health care providers in almost every type of Medicare and Medicaid appeal. We have represented hundreds of providers before the Provider Reimbursement Review Board (PRRB), Administrative Law Judges and the HHS Departmental Appeals Board (DAB), the Federal District Courts, the Federal Courts of Appeals, and other federal and state administrative tribunals and courts in complex Medicare and Medicaid reimbursement appeals, coverage appeals, enrollment appeals, and termination appeals. We have argued over 50 cases at hearings in Medicare cost report and claims appeals. We have also handled Medicaid reimbursement appeals before state agencies and courts. Our considerable experience will benefit your company, as we work with you to evaluate a claim denial and structure a cost effective strategy for an appeal. Our expertise and success rate enable us to add value at any stage of the appeals process.

 

Medicare Cost Report Appeals

 

  • Significant experience and long track record of success in cases of all sizes, from individual single issue appeals to large group appeals with close to 200 providers.
  • Represented many common issue related party (CIRP) and non‐CIRP groups before the PRRB. These have been some of the largest group appeals brought before the PRRB, which require close tracking and attention to detail.
  • Significant experience and success with home office cost issues, bad debt, provider taxes, IRF-PAI late penalty appeals, and long-term acute care hospital (LTCH) reimbursement issues, to name a few.

 

Medicare Claims Appeals  


  • Significant experience with hospital (including LTCH and IRF), skilled nursing facility, hospice, and home health claims appeals.
  • We can provide assistance with appeals from:
    • Recovery Audit Contractors (RACs)
    • Fiscal Intermediary (FI) / Medicare Administrative Contractor (MAC) Pre- and Post-Pay Reviews
    • Medical Necessity Reviews of LTCH Claims
    • Quality Improvement Organizations (QIO) Reviews
    • Statistical Sampling and Extrapolation Audits by:
      • Program Safeguard Contractors (PSCs)
      • Zone Program Integrity Contractors (ZPICs)
    • Comprehensive Error Rate Testing (CERT) Auditors

Medicare Statistical Sampling Appeals

 
  • When Medicare contractors use statistical sampling and extrapolation for overpayment estimation, the result is often a huge overpayment demand to the provider.
  • It is not uncommon for a Medicare contractor to use a sample size of 30 claims or less to estimate an overpayment of $1 million or more. This can impose serious financial strains on a hospital or other health care provider.
  • These cases also present unique challenges. Although the statistical methodology and extrapolation can be challenged by the provider, it is necessary to have a qualified statistical expert and an experienced appeal representative who understands how to effectively argue these issues in written briefs and at the hearing.
  • Our proven strategy uses statistical experts and medical experts to challenge both the statistical sampling and the individual claim determinations.
  • In many cases, the entire overpayment demand, or a significant portion thereof, has been reversed on appeal by challenging the statistical sampling itself.
  • This can have the added benefit of deterring Medicare contractors from conducting similar audits in the future.

 
Medicare Coverage Appeals

 

  • Direct challenges to National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs)

 

Medicare Enrollment Appeals

 

  • Effective date challenges

 

Medicare Termination Appeals

 

  • Hospital and other provider de-certification appeals
  • LTACH and IRF reimbursement de-classification appeals

 
State Medicaid Reimbursement Appeals

 

  • Both cost report and claims appeals in all states, including judicial review by state courts. Some of the states where we have handled Medicaid cases include:
    • District of Columbia
    • Virginia
    • Maryland
    • Idaho

 

PRELIMINARY STAGES:  WE HELP CLIENTS RESPOND TO PROPOSED ADJUSTMENTS OR OVERPAYMENTS, BEFORE DENIALS OCCUR, TO BEST POSITION THE PROVIDER FOR REIMBURSEMENT

 

Reimbursement disputes often begin well before an appeal is filed. We regularly work with clients in these early stages to develop a persuasive legal position utilizing our in-depth knowledge of Medicare and Medicaid reimbursement, coverage, and certification rules. Whether it is developing a response to a proposed cost report adjustment, a rebuttal to a program safeguard contractor (PSC/ZPIC), or a discussion period response to a recovery audit contractor (RAC), we have had success in achieving the client's desired outcome without the need for an appeal.

 

We advise clients on ways to avoid payment denials in the first place or to preserve a reimbursement issue for later appeal. For example, we counsel health care providers on how to properly file cost reports with protested items in order to preserve the right to appeal certain issues to the PRRB. Our goal is to help the provider best position itself for reimbursement and, if necessary, an effective appeal to secure such reimbursement.

 

FORMULATING A STRATEGY:  WE DEVELOP AN APPEAL STRATEGY TO MAXIMIZE YOUR CHANCES OF SUCCESS

 

We work in a collaborative manner with the client's in-house legal counsel and reimbursement department to develop an effective and efficient appeal strategy tailored to each case.

 

We look for ways to create opportunities to engage the agency in settlement discussions or mediation to reduce appeal costs and to obtain a favorable result for the client. This process begins by developing a persuasive case on the legal and factual issues, drawing from our years of experience with Medicare and Medicaid reimbursement rules and appeals. In many instances, we can provide added value to clients when a case involves issues from pending or prior appeals that we have already researched and developed legal arguments. For cases involving technical issues of a non-legal nature (such as statistical sampling or medical necessity of care), we often use one of our expert witnesses to provide the credible, independent opinion that is needed to overcome the agency's adverse findings.

 

We have experience with formal mediation programs at the administrative and federal court levels. We have utilized these programs to achieve favorable results for clients.

 

More often, we have had success in resolving cases through informal settlement discussions with agency representatives. Over the years, we have established a number of useful contacts at CMS, the fiscal intermediaries and MACs, administrative boards, and courts. Our experience working with these individuals allows us to negotiate administrative resolution in many cases, to otherwise move cases more efficiently through the appeals process, and to maximize the provider's chances of success.

 

MANAGING YOUR APPEAL:  WE HANDLE EVERY ASPECT OF THE APPEAL PROCESS AS YOUR AUTHORIZED APPEAL REPRESENTATIVE

 

As your appeal representative, we provide legal assistance through the entire administrative appeal process from the initial appeal through judicial review by the courts, if necessary. We understand the often complex procedures for navigating appeals effectively within the agencies, administrative boards, and the courts, where a missed deadline can sometimes mean automatic dismissal of the case.

 

We will work in a collaborative manner with your internal appeals group or reimbursement department to:

 

  • Help coordinate appeals and devise an appeals strategy
  • Track appeal due dates and coordinate filings
  • Review documentation and suggest areas to supplement the record
  • Prepare or refine factual case summaries
  • Identify and prepare legal arguments
  • Prepare or review appeal filings
  • Prepare designated professionals and/or experts to testify at hearings
  • Prepare all pre- and post-hearing filings
  • Argue the case at hearing, direct testimony of witnesses, and cross-examine agency witnesses

 

JUDICIAL REVIEW:  WE LITIGATE MEDICARE AND MEDICAID CASES IN FEDERAL AND STATE COURTS

 

We have successfully obtained expedited judicial review in cases involving regulatory challenges and other pure issues of law. In other cases, where relief cannot be obtained through settlement or administrative decision, we have utilized the federal and state courts to provide judicial review.

 

Our location in Washington, D.C. gives us a distinct advantage due to our close proximity and regular interaction with the Provider Reimbursement Review Board, the HHS Departmental Appeals Board, and the United States District Court for the District of Columbia. All Medicare cost report appeals are filed with the PRRB in Baltimore, Maryland. The DAB is based here in the District. The DAB's Medicare Appeals Council considers all Medicare claims appeals from ALJ decisions. The DAB's Appellate Division hears other types of cases, including Medicare decertification cases. Many, if not most, Medicare cases on judicial review are filed here, with the United States District Court for the District of Columbia. Our local presence is particularly useful for in-person hearings, which are still common.

Representative Appeal Matters

 

Obtained full waiver of $1 million in IRF-PAI late penalties for IRF hospital using two-track appeal strategy


Successfully negotiated fully favorable settlement of Medicare outlier reconciliation for LTCH hospital


Successfully negotiated $24 million settlement of 27 large group Medicare reimbursement appeals of home office costs for leading skilled nursing facility chain

 

Obtained favorable ALJ rulings in 3 separate Medicare overpayment cases involving extrapolation from a statistical sample

 

Obtained favorable ALJ rulings in dozens of LTCH claims appeals from WPS medical necessity reviews

 

Obtained series of favorable decisions on "must bill" and other Medicare bad debt issues in hospital group and skilled nursing facility appeals

 

Obtained favorable decision in hospital provider tax case for national hospital chain

 

Successfully negotiated settlement of first Medicare reimbursement classification case under "75% rule" for inpatient rehabilitation hospital

 

Successfully negotiated fully favorable settlement of Medicare enrollment effective date appeal for inpatient rehabilitation hospital

 

Helped negotiate $60 million settlement of hospital lease expense appeals for 80 hospitals through PRRBsponsored mediation

 

Successfully negotiated settlement of related Virginia Medicaid appeal

 

Helped settle qui tam False Claims Act case against national hospital chain and resolution of multiple government investigations