Medicare, Medicaid, and Other Commercial Payor Audits & Appeals

Medicare, Medicaid, and Other Commercial Payor Audits & Appeals

When a Medicare claim is denied or reopened for post-payment review, providers must navigate a complicated appeals process, the outcome of which can range from an educational directive, to a substantial overpayment demand.  At times, audits can lead to referrals to enforcement agencies for criminal prosecution of healthcare fraud, civil litigation, administrative penalties and possible program exclusion.  While all payor audits must be taken seriously and handled with care, Medicare audits involve a complex matrix of laws, rules, and policies can become traps for the unwary.  The key to successfully navigating this minefield is preparation, knowledge, and experience. 

There are several considerations when responding to any payor audit, including but not limited to:

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

A conflict of interest may exist when a billing company attempts to address a recoupment that is based on billing and coding issues that were created by them.  An attorney versed in the Medicare appeals process is better suited to represent the provider’s interests and detect oversights or potential negligence by the billing company.

Medicare Appeals require a formal approach to be successful.

Medicare appeals generally require multiple individual appeals, each with its own procedural requirements.  If the time to respond to a Medicare contractor is miscalculated and a deadline missed, the practice will not be able to appeal the outcome.  If supporting documents, including attestations, medical records and/or expert reports, are not included at a certain point in the appeals process, they cannot be supplied or relied upon at a hearing.  Medicare appeals have specific rules governing everything from what documents need to be presented at what stage in the appeals process to how the CMS calculates when it deems an appeal “received” by CMS contractors.  A cavalier attitude towards the CMS appeals process can result in calamity for a practice of any size. 

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

Many providers mistakenly believe that their reliance on a third-party billing company immunizes them from penalties. No matter who codes and bills, the Medicare provider is ultimately responsible for the claims, and bears the consequences. The Federal government engages a variety of contractors that aggressively investigate Medicare fraud, waste, and abuse, recover overpayments, and make referrals to enforcement agencies.  Cases that escalate as a result of referrals to the HHS – Office of the Inspector General and the Department of Justice may involve treble damages, civil money penalties, exclusion from the Medicare program, and in some cases, criminal prosecution. 

Providers should always challenge findings and rely on qualified healthcare counsel to represent them in these potentially high stakes matters.

Our attorneys are skilled in the appeals process and the laws and rules governing coding and billing for Medicare, Medicaid and other commercial audits. Our attorneys have successfully helped clients to mitigate the impact of Medicare and commercial payor audits and clawbacks.  In recent years, we have been successful in reducing the original error rates (in some cases by as much as 90%), recovering hundreds of thousands of dollars inappropriately recouped from our clients, and reducing overpayment demands by millions of dollars.  The theme in nearly every case is that auditors need to be challenged as their subjective findings are many times wrong and biased towards the auditing entity.   

How Frier Levitt Can Help

If you have questions about the Medicare Audit Appeals process or need help responding to a Medicare (or other payor) audit or filing an appeal, contact Frier Levitt to speak with an attorney.

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