Should your clinic or practice be subjected to a government contractor review or audit by either a Recovery Audit Contractor (e.g. Connolly Healthcare) or a Program Safeguard Contractor (e.g. AdvanceMed), it is imperative that you fully exercise your appeal rights. To properly do so, you should seriously consider engaging a qualified law firm to protect your interest. While all providers know that they have the right to contest claims denials based on medical necessity and other claims-specific defenses, they are typically not able to challenge the alleged overpayment based on legal insufficiency (i.e. the CMS contractor lacked a proper legal basis to reopen these otherwise payable claims in the first place). Providers also have the right to contest the validity of the statistical extrapolation. In opposing the imposition of extrapolated damages, there are both legal and statistical issues that must be assessed when seeking to have the extrapolation invalidated by the Court.
Medicare Claims Processing Guidance
Each year, the Centers for Medicare and Medicaid Services (CMS) issues extensive guidance covering claims coding, billing and processing. Providers must remain vigilant in their efforts to better ensure that services are provided in accordance with applicable laws, regulations and CMS contractor guidance. Recent estimates have placed the scope of applicable guidance at over 80,000 pages. The practice of medicine has become frustrating, bureaucratic and in many cases expensive for health care providers trying their very best to comply with the myriad rules and regulations governing their practice and participation in the Medicare program.
In 2009 alone, Liles Parker has represented providers in connection with the appeal of well over 10,000 separate Medicare claims alleged to constitute overpayments by CMS contractors. We analyze the regulatory guidance, including, but not limited to applicable LCDs, LMRPs, and NCDs relied upon by the contractors when denying these claims.
In recent years, we have seen CMS and their agents increasingly rely on statistical extrapolation estimates when assessing claims overpayments. In extrapolating damages, CMS contractors have attempted to force many providers to repay most, if not all, of the monies paid over multi-year periods. In these cases, a contractor may review a small number of claims (sometimes involving as few as 30 beneficiaries), often identifying both technical and substantive errors. In several of the cases we have handled, the purported percentage of claims where errors have been identified exceeds 90%. The contractor would then extrapolate this percentage of errors to the universe of Medicare claims paid to the provider over the years. The resulting alleged damages are often in the millions of dollars. Few providers are in a position to merely pay such an overpayment. Instead, they must aggressively fight in an effort to have this overpayment overturned.
Reviews and Appeals
A and Part B cases. When representing providers, we carefully analyze your particular case and the claims that have been denied by CMS contractors. While no two cases are exactly alike, through years of experience handling these types of cases, we have identified the legal and medical necessity arguments and strategies necessary to persuasively represent your case. Our approach includes, but is not limited to:
oReviewing the specific facts in your case and asserting a number of legal arguments and citations designed to overturn the contractor's contention that the claims at issue should not be paid.
oAnalyzing the statistical methodology employed in extrapolating the alleged damages to determine whether the methodology complies with CMS requirements and is consistent with accepted statistical methods and practices. When necessary, we engage a Ph.D.- level statistician to assess the validity of the extrapolation and testify in a proceeding before an ALJ regarding the deficiencies.
Questions to Ask a Prospective Attorney
Before you engage counsel, you should consider asking the following questions: (1)Has the attorney ever handled large, complex contractor audits before? Some firms will happily take you case, despite the fact that they have little or no experience in this area of health law. Don't pay for your attorneys to learn how to handle a case. While every case is different, an experienced firm will have developed a number of arguments and defenses that may be readily used in your case, without having to conduct costly, extensive legal research. (2) Can the firm provide client references who are willing to speak with you about the quality of work performed on their Medicare statistical extrapolation case? (3) Who will be working on your case -- an inexperienced Associate attorney or one of the partners who has actually fought and won a multitude of Medicare overpayment claims and cases where the damages have been extrapolated by the contractors? (4) What are credentials of the attorneys?
Our attorneys represent health care providers in connection with a full range of health care audits, investigations and prosecutions. Providers are now under the scrutiny of a multitude of government agencies and their contractors. Liles Parker represents health care providers in connection with a wide range of ZPIC, RAC and PSC audits. Should you receive notice of an audit or investigation, please feel free to give us a call. There is no charge for an initial evaluation of your audit or case. 1 (800) 475-1906.
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