Assisting Clients With Medicare And Commercial Carrier Overpayment Appeals
At some point, nearly every health care provider, including sole practitioners, home health agencies, durable medical equipment providers, physician groups and ambulance companies, will receive a demand for an overpayment from Medicare and commercial carriers.
At Rivas Goldstein, LLP, our attorneys provide skilled representation in overpayment matters and handle all stages of Medicare and commercial carrier overpayment appeals. Our attorneys provide comprehensive representation in overpayment matters, from responding to ZPICs “Safeguard Services” (Zone Program Integrity Contractors) through handling all stages of an overpayment appeal.
How Are Overpayment Determinations Made?
Many government-contracted entities have the authority to determine overpayment. Some of these include Recovery Audit Contractors (RACs), Medicaid Integrity Contractors (MICs), ZPICs “Safeguard Services” and Medicare Administrative Contractors (A/B/MACs).
In many cases, the government claims there were millions of dollars of overpayments based on faulty extrapolation methods. At Rivas Goldstein, LLP, our attorneys have been successful in contesting overpayments based on extrapolation.
How Does The Appeal Process Work?
The process is the same for all health care providers, from physicians to home health agencies to suppliers. There are five levels of the Medicare and commercial carrier appeal. Our New York City lawyers can represent clients at any of these levels:
- Level 1 — Request for redetermination: At this stage, the provider requests that the Medicare and commercial carrier contractor reevaluate the overpayment allegation. The contractor will provide a written decision, either changing the initial determination or denying the claim. If the claim is denied, go to level 2.
- Level 2 — Request for reconsideration: Here, Medicare and commercial carrier overpayment appeals are assessed by a qualified independent contractor (QIC) chosen by the Centers for Medicare & Medicaid Services (CMS). Legal counsel is valuable at this level because it is the last chance for a provider to submit new documentation to challenge the overpayment allegation.
- Level 3 — Request for OMHA ALJ hearing: Providers who are not satisfied with the outcome of reconsideration can request a hearing before an administrative law judge (ALJ) at the Office of Medicare Hearings and Appeals (OMHA). This process includes a discovery phase and witness testimony, much like a civil lawsuit.
- Level 4 — Medicare Appeals Council (MAC): If the ALJ decision is not satisfactory to the provider, the matter can be taken to the MAC. This step is a written appeal. Our attorneys handle the entire proceeding on your behalf.
- Level 5 — U.S. District Court: The last avenue of appeal for providers and suppliers is to file a lawsuit in federal court. Only an attorney admitted to practice before a federal court can present these cases.
Experience You Can Trust In Overpayment Appeals
At Rivas Goldstein, LLP, the health care law team has the collective knowledge, experience and resources needed to see an overpayment appeal through to its completion. We thoroughly analyze the situation, including the error rates, extrapolation techniques used by the contractor. We look strategically at each case, testing the legal and factual bases for the overpayment determination.
Our lawyers attend all hearings, ensuring that our clients have the opportunity to clear the record. We also undertake negotiations to reduce the amount a client owes in fines or reimbursements for alleged overpayments.