Frier Levitt Secures a Two-Million Dollar Medicare Appeal for Cardiology Group

Recently Frier Levitt pursued a Medicare appeal for a cardiology group that faced a 2.4-million dollar recoupment. Frier Levitt was able to have over 2-million dollars of the recoupment reversed at the redetermination stage (first level of appeal). This result is just one of the reasons why providers should seek guidance from qualified healthcare attorneys when faced with a Medicare audit. Here are a few other reasons:

Medicare rules in general, and the appeals process in particular, are codified in a complex body of regulations known as administrative law. However, many healthcare providers rely on non-lawyers, typically billing staff, to file their Medicare appeals. This approach exposes the provider to substantial risk, as the foundation of any successful appeal is a thorough understanding of the procedural and substantive rules that make up the appeal process, and the Medicare appeals process is quite complex.

There are five levels of a Medicare appeal: (1) redetermination by a CMS contractor, (2) reconsideration by a qualified independent contractor, (3) hearing before an administrative law judge, (4) review by the appeals council, and finally (5) judicial review in federal district court. Each level of the appeal process has its own requirements and time limits for filing. Failure to satisfy these requirements, such as missing an appropriate deadline, can extinguish future appeal rights. Furthermore, presenting arguments and evidence at an inappropriate stage of the process may create inadmissibility at later stages. An experienced healthcare attorney is best suited to help practitioners navigate this area of administrative law in order to avoid irreparable errors.

It is imprudent to rely on the person or entity that made the original billing error to conduct the appeal.

During a Medicare audit, contractors will make an attempt to recover any federal funds paid as the result of a billing error. Many providers utilize third-party billing companies to process their claims. It is an ill-advised approach to allow the same billing company that made the original errors to attempt to defend those errors in the appeals process, particularly without oversight or assistance by individuals experienced in the appeals process. A billing company that is responsible for a Medicare error resulting in a recoupment has a direct conflict of interest in addressing the appeal process. The billing company has a vested interest in shifting the blame for recoupment to the provider in an effort to avoid liability. Moreover, the existence of these billing errors that subject the provider’s payment to recoupment may indicate that the billing company is not knowledgeable or currently competent to implement practices in compliance with Medicare regulations. An attorney versed in Medicare law is better suited to represent the provider’s interests and act as a barrier of protection to detect oversights or potential negligence by the billing company.

Medicare fraud is a crime and the penalties for abuse can be significant.

Medicare enforcement is on the rise. The federal government has a variety of contractors and task forces that are aggressively pursuing Medicare fraud, waste, and abuse. The government’s efforts to combat health care fraud resulted in a recovery of $4.3 billion in fiscal year 2013 and $19.2 billion since 2009. Many Medicare contractors are even paid “bounties” based on the overpayments that they recover, incentivizing a strict culture of review. Last year, Medicare auditors kept $142.3 million of the federal money that was recaptured.

Aggressive investigations by the Office of the Inspector General and the Department of Justice frequently result in the recoupment of overpayments, and may involve treble damages, civil money penalties, and criminal prosecution. In addition to recoupment of funds, provider may also face potential exclusion from the Medicare program. Exclusions may be permissive or mandatory—the distinction between the forms of exclusion is relative to the particular misconduct on the part on the provider. However, mandatory exclusion has a minimum period of five years and may result in mandatory permanent exclusion in certain circumstances. Exclusion can be crippling for individual providers as well as large medical groups.

Frier Levitt has a team of attorneys experienced in Medicare appeals with a proven track record of success at various levels of the appeals process. We have attorneys on staff that have managed large professional medical billing operations and are experts in Medicare law. In addition to the recent $2 million recovery, Frier Levitt has succeeded in dozens of Medicare appeal matter for its clients. Contact us to speak to an attorney.

Past experience in no guaranty of future results and each client’s case is different.

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