When a Medicare provider has a claim denied or reopened, they face the difficult task of interpreting the complex matrix of laws, rules, and policies when attempting to file claims with the Centers for Medicare and Medicaid (CMS) for services provided to Medicare recipients.
CMS further complicates this process by providing “guidance” through a variety of resources, including position papers, clarification letters, provider seminars, and internet postings. It is not uncommon for CMS rules to be in conflict with one another, further frustrating the efforts of providers to adjudicate claims. At times, the CMS’ auditors will rely upon Local Coverage Determinations (LCDs) that are not binding, have been discontinued, or that have not been enacted yet. In short, when the CMS wants a result, they will find a way to achieve it, even if it means creating requirements ex post facto.
This requires providers responding to unfavorable Medicare findings to dive deep into the rationale, double check every source, and never accept the findings at face value.
The substance of an appeal can range from simply providing additional documentation to challenging CMS policies or delving into complex procedural, clinical, coding, and/or scientific arguments. The key to a successful appeal is preparation, knowledge, and experience.
Our attorneys are uniquely skilled in both the appeals process and the laws and rules governing Medicare coding and billing. We have successfully recovered millions of dollars on behalf of our clients with some cases exceeding $9 million in exposure.
Frier Levitt provides strategic, industry-focused legal counsel tailored to your needs. Contact our team today to learn how we can help you.
