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 individual providers, and common issue related party (CIRP) and non‐CIRP groups, before the Provider Reimbursement Review Board (PRRB), the CMS Administrator, and the federal courts, including some of the largest group appeals brought before the agency and direct challenges to federal regulations
Significant experience and success with provider costs, bad debts, quality reporting programs, outlier reconciliations, home office costs, provider taxes, and IRF-PAI late penalty appeals, to name a few
Significant experience with hospital (including LTCH and IRF), skilled nursing facility, hospice, and home health claims appeals, including statistical sampling and extrapolation.
We provide assistance with audits and appeals from:
We are one of the leading firms representing health care providers in appeals of non-compliance determinations under the Medicare quality reporting programs (QRPs). Our years of experience with these appeals have resulted in favorable outcomes for many clients at the agency and before the federal courts. Some of the quality reporting programs at issue in the appeals we handle include:
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
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
Direct challenges to:
Appeals of:
Hospital and other provider de-certification appeals
LTCH, IRF and IPF reimbursement de-classification appeals
Cost report and claim appeals in all states, including judicial review by state courts. Some of the states where we have handled Medicaid cases include:
Appeals, arbitrations, civil actions, and negotiated settlements in refusal to pay cases involving commercial payors, third party administrators and network agents
Obtained over $25 million for hospital groups after a series of favorable decisions on "must bill" and other Medicare bad debt issues
Obtained full waiver of $1 million in IRF-PAI late penalties for IRF hospital using two-track appeal strategy
Successfully negotiated $24 million settlement of 27 large group Medicare reimbursement appeals of home office costs for leading skilled nursing facility chain
Successfully negotiated fully favorable settlement of Medicare outlier reconciliation for LTCH hospital
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 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 PRRB‐sponsored 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
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:
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.
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