ZPIC Audits Involving Extrapolated Damages Can Bankrupt Your Practice.
(January 30, 2013): The Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (also referred to as “BIPA”), amended Section 1869 of the Social Security Act, resulting in a number of significant changes to the way administrative appeals of denied Medicare claims are handled. One change in particular has greatly simplified the Medicare appeals process. BIPA established a uniform process for handling both Medicare Part A and Part B administrative appeals. I. ZPIC Audits Involving Extrapolated Damages Have Become Quite Common. Unlike the Medicaid administrative claims appeal process (which varies from state to state), thanks to BIPA, the Medicare administrative appeals ...
Medicare Appeals Have Become More Complex Than Ever.
(January 21, 2013): Medicare appeals of denied claims for services are somewhat common. In years past, both health care providers and members of their staff have represented themselves or their practice in the administrative process. While the rules of participation are quite lenient, the process has significantly changed over the last decade. Moreover, in recent years, contractors working for the Centers for Medicare and Medicaid Services (CMS) have assumed a much greater role in the Medicare appeals process. Hearings conducted in today's administrative appeals of alleged Medicare overpayments are likely to be quite different from those conducted even a few years ago. Should you decide to ...
Medicare Appeals — Filings with the Office of Medicare Hearings and Appeals Switch to a Central Docketing System.
(March 1, 2012): Medicare appeals of denied claims arising out of audits conducted by Zone Program Integrity Contractors (ZPICs) and Recovery Audit Contractors (RACs) has significantly increased as administrative enforcement efforts have expanded around the country. While workloads have generally risen across the board, the number of cases handled from one ZPIC to another has resulted in an enormous disparity in workload for the various Field Offices of the Office of Medicare Hearings and Appeals (OMHA). I. Medicare Appeals Will Now be Handled Through a "Central Docketing System": As a result, OMHA recently switched to a "Central Docketing System" for all pending and new Medicare ...
Lose Your Medicare Appeal at Reconsideration? Don’t Throw in the Towel Just Yet — Consider the Consequences and Your Options.
(June 18, 2011): As a review of the last several quarters of Medicare appeals statistics reflects, an overwhelming percentage of Medicare providers appealing alleged overpayments through the Medicare administrative appeals process have chosen to “throw in the towel,” so to speak, when they have lost at the reconsideration level. As you will recall, at the reconsideration level, Medicare claims are assessed by a Qualified Independent Contractor (QIC) selected by the Centers for Medicare and Medicaid Services (CMS) to hear the second level of administrative appeals. According to statistics kept by Q2Administrators, the contractor selected to serve as the Administrative QIC (AdQIC), ...
Is Your Medicare Appeal Now at the ALJ Level? What Should You Expect?
(February 19, 2011): Over the years, we have represented a wide variety of health care providers in the Medicare appeals process. Our duties have regularly included representation before Administrative Law Judges (ALJs) presiding out of the Western, Southern, Midwestern and Mid-Atlantic Field Offices of the Office of Medicare Hearings and Appeals. (OMHA). In the course of our work, we have routinely been asked by our health care provider clients for our opinion regarding the “independence” of ALJs from the pressures exerted by the Centers for Medicare and Medicaid Services (CMS) and its contractors (including, but not limited to the Qualified Independent ...
Has Your “Win” Before an ALJ Been Referred to the Medicare Appeals Council by the AdQIC?
(December 29, 2010): I. Introduction: Many health care providers are familiar with the revised administrative appeals process for contesting denied Medicare claims. In exercising their appeal rights, many providers (or their legal counsel) have appealed denied claims through the second level of appeal, submitting their claims and arguments in support of payment to the Qualified Independent Contractor (QIC) responsible for hearing reconsideration appeals. Q2 Administrators (Q2A) is one of the contractors selected by the Centers for Medicare and Medicaid Services (CMS) to serve as a QIC. Notably, Q2A has also been awarded the first task order to serve as Administrative Qualified Independent ...
ZPIC Contractors are Turning Up the Heat.
(September 1, 2010): I. Introduction -- ZPIC Contractors Are Likely to Participate in Your ALJ Hearing: As previously discussed, after representing health care providers for many years in administrative hearings, involving well over 10,000 Medicare claims this year alone, it has been our experience that Administrative Law Judges (ALJs) remain a provider’s single best opportunity to present its legal, regulatory and factual arguments in support of payment. While there are no guarantees, the ALJs we have practiced before have been attentive, knowledgeable, willing to listen to the provider’s viewpoint, and perhaps most importantly, FAIR. In recent years though, it has become more ...
Health Data Insights Begins Medical Necessity Reviews
(August 30, 2010): I. Introduction -- "Medical Necessity" Issues Presented: Health Data Insights (HDI), the Centers for Medicare & Medicaid Services (CMS) Recovery Audit Contractor (RAC) responsible for auditing health care providers in Region D, has announced it will immediately begin reviews on previously approved projects which involve the medical necessity of selected inpatient DRG payments. A complete list of the medical necessity “issues” currently being examined by HDI can be found on its Website. II. Scope of Responsibilities Assigned to Health Date Insights: RACs, such as HDI, contract with the CMS to perform post-payment reviews of Medicare claims to find overpayments ...
RACs Are Auditing Your Claims — What Should Physicians and other Medicare Providers Know about Appeals and Recoupment?
(July 2, 2010): CMS’ Recovery Audit Contractor (RAC) program is now permanent and nationwide. As we discussed in Part I of this series, while small providers were largely ignored during the demonstration program, physicians, home health, hospice, and durable medical equipment (DME) suppliers should be on the lookout for increased attention. In Part II, we discussed some ways providers can prepare for and respond to an audit request. In this Part III, we will discuss a provider’s appeal options in the event that a RAC identifies an alleged overpayment as a result of its audit. It is important to remember that ...
You’ve got to be kidding. . . more Medicare audits on the way?
(March 11, 2010): Medicare audits can be extraordinarily stressful for your organization. Are your documentation practices compliant? If not, you should take immediate steps to address any deficient practices you might have. New Medicare audits are on the way! According to the White House, President Obama has announced that he intends to back bipartisan plans to stamp out waste in government-run medical programs for the elderly and needy. The White House said the new effort to root out improper payments in the Medicare and Medicaid programs could double taxpayer savings over the next three years to at least $2 billion. I. The White ...
ALJ Appeal
Medicare Appeals Have Become More Complex Than Ever.(January 21, 2013): Medicare appeals of denied claims for services are somewhat...
Medicare Appeals — Filings with the Office of Medicare Hearings and Appeals Switch to a Central Docketing System.(March 1, 2012): Medicare appeals of denied claims arising out of audits conducted...
Lose Your Medicare Appeal at Reconsideration? Don’t Throw in the Towel Just Yet — Consider the Consequences and Your Options.(June 18, 2011): As a review of the last several quarters of Medicare appeals statistics...
Is Your Medicare Appeal Now at the ALJ Level? What Should You Expect?(February 19, 2011): Over the years, we have represented a wide variety of health...
Be Prepared — ZPIC and QIC Representatives Are Increasing their Participation in ALJ Appeal Hearings.(February 12, 2011): Over the last year, we have noted an important trend when...
Read More Posts From This CategoryGuidance
ZPIC Audits Involving Extrapolated Damages Can Bankrupt Your Practice.(January 30, 2013): The Medicare, Medicaid, and SCHIP Benefits Improvement and Protection...
Has Your “Win” Before an ALJ Been Referred to the Medicare Appeals Council by the AdQIC?(December 29, 2010): I. Introduction: Many health care providers are...
ZPIC Contractors are Turning Up the Heat.(September 1, 2010): I. Introduction — ZPIC Contractors Are Likely...
Health Data Insights Begins Medical Necessity Reviews(August 30, 2010): I. Introduction — “Medical Necessity”...
Hang on tight — 2010 could be rough . . .(March 1, 2010): The number of auditors, reviewers, investigators and prosecutors...
Read More Posts From This CategoryMedicare Audits
RACs Are Auditing Your Claims — What Should Physicians and other Medicare Providers Know about Appeals and Recoupment?(July 2, 2010): CMS’ Recovery Audit Contractor (RAC) program is now permanent and nationwide. As we discussed in Part I of this series, while small providers were largely ignored during the demonstration program, physicians, home health, hospice, and durable medical equipment (DME) suppliers should be on the lookout for increased attention. ... [Read more of this review]
A Look at RACs — How Should Physicians and Other Providers Respond to a RAC Audit?(June 28, 2010): In Part I of this series, we reacquainted you with the design and purpose of the now permanent Recovery Audit Contractor (RAC) Program. Although RACs largely focused on inpatient care during CMS’ demonstration program, RACs are a real threat to small providers that don’t have the intensive compliance programs in place that most... [Read more of this review]
A Look at RACs: What Do Physicians, Home Health, Hospice, and DME Providers Need to Know?(June 25, 2010): The purpose of this series of articles is to assess the Recovery Audit Contractor (RAC) Program from the perspective of physicians, home health, hospice, durable medical equipment (DME) providers, and other relatively small Medicare providers. As many non-hospital providers will acknowledge, early cries of wolf by law firms and consultants... [Read more of this review]
You’ve got to be kidding. . . more Medicare audits on the way?(March 11, 2010): Medicare audits can be extraordinarily stressful for your organization. Are your documentation practices compliant? If not, you should take immediate steps to address any deficient practices you might have. New Medicare audits are on the way! According to the White House, President Obama has announced that he intends to back... [Read more of this review]
Final Rule Outlining Recoupment Limitations and the Impact on Ongoing Medicare Overpayment Appeals Cases(February 1, 2010): Last September, the Centers for Medicare and Medicaid Services (CMS) published its Final Rule addressing limitations on the recoupment of alleged overpayments by its Medicare contractors (e.g. Medicare Administrative Contractors and Qualified Independent Contractors). This Final Rule finalizes how Medicare contractors are to... [Read more of this review]
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