Medicare Appeals and Audit Consulting

Medicare providers and suppliers continue to face increased scrutiny from a variety of Medicare contactors, including RACs, ZPICs and the Medicare Administrative Contractors (MACs). As a result, many providers find themselves faced with defending claim denials or multi-beneficiary retrospective audits through the multi-level Medicare appeals process.

Our health law attorneys have assisted providers, suppliers and Medicare beneficiaries appeal thousands of Medicare claim denials.  Our attorneys have experience handling multi-claim retrospective audits, pre-payment audits, and single claim denials with a variety of Medicare contractors.

Early Stage Audit Consulting

For audits involving multiple claims, we can assist your office from the beginning of the audit process upon receipt of the medical records request letter.  We are experienced in evaluating audit requests and helping your health care business to develop an organizational structure that will allow you to effectively manage the submission of requested documents and audit deadlines.  Once the audit results are received our attorneys will evaluate the audit findings and formulate an effective individualized strategy for appeal.

Individualized Medicare Appeal Strategy

Our experience in this area allows us to develop a Medicare appeal strategy that fits your needs.  We will work with you to develop a comprehensive strategic approach that provides the services you need while allowing you to retain control over those aspects that you prefer to continue to manage.  If desired, our health law attorneys can handle all aspects of your Medicare appeal including the submission of all documentation through the redetermination, reconsideration, Administrative Law Judge (ALJ) and Medicare Appeals Council levels of appeal as applicable.  During this process, our attorneys will work with you to develop an appeal strategy and develop legal arguments, including the drafting of position papers and briefs to support these arguments.   Our attorneys can also assist with evaluating the need for and coordinating the use of experts to defend substantive issues such as medical necessity and argue your case at the ALJ hearing.
As a more affordable option or for those providers or suppliers who prefer a more hands on approach, we also offer audit consulting services where we will guide you through the appeals process, consult with decision-makers on strategic appeal decisions and identify key deadlines, all while developing an organizational structure that your internal staff can manage cost effectively.  Depending on the nature of the audit, our audit consulting services can significantly reduce the cost of audit defense by allowing our attorneys to focus on developing the substantive legal arguments in order to defend against the audit claim denials, while structuring the appeal so that management of the medical records and audit submissions can rest with your staff.

Some of our audit defense and audit consulting services include:

  • Evaluating audit request letters and audit result letters
  • Identifying the applicable appeals process and key deadlines on appeal
  • Identifying strategic considerations, such as opportunities to limit the recoupment of current payments while on appeal
  • Drafting response letters and requests for information to Medicare contractors and third party payors
  • Discussions regarding the involvement of clinical experts, including internal staff members or outside experts
  • Researching applicable statutory, regulatory and sub-regulatory guidance, coverage policies and documentation requirements
  • Evaluating claim denials in light of applicable coverage and documentation guidance
  • Development of a substantive written position paper for submission on appeal
  • Development of an organizational structure for the effective management and tracking of the appeal, incorporating your internal staff where desired
  • Appearance at an administrative law judge (ALJ) hearing or managerial level conference

Some provider/supplier types that our attorneys have represented in Medicare appeals and other payor appeals include:

  • Physicians
  • Nurse practitioners
  • Hospitals
  • Clinical laboratories
  • Ambulance suppliers
  • Durable Medical Equipment (DME) suppliers including power wheelchair suppliers
  • Orthotic and prosthetic suppliers
  • Physical therapy providers
  • Skilled Nursing Facilities (SNFs)
  • Home health agencies
  • Hospices

Representation of Medicare Beneficiaries in Medicare Appeals

While it is not always cost effective for beneficiaries to hire an attorney to appeal a Medicare decision, in some instances it makes financial sense to do so.  For example, when Medicare denies high ticket items such as power wheelchairs or artificial limbs or denies services such as skilled nursing or home health.  In these cases, it may be financially prudent for beneficiaries facing termination of future services or financial liability for the services or items provided to appeal the Medicare decision.