ALJ Appeals: Pay attention to details

Q. What are some best tips for defending claims—from ADR letters to ALJ appeals?
Thursday, September 29, 2016

A. A home medical equipment supplier can protect its profit margins from recoupment by establishing a compliance culture that collects adequate documentation and submits proper billing claims, but it is equally important for a supplier’s bottom line to defend and appeal erroneous Medicare recoupments. 

Below are a few tips for defending claims from start to finish.

Help Your Attorney

Involving an attorney at the ADR letter stage is not always necessary, but a response that does not provide adequate information to support the claim, or a failure to respond to an ADR letter, can have a lasting impact on an attorney’s ability to defend a supplier on appeal. Therefore, a supplier should provide a complete, well-rounded response to the contractor’s request for additional documentation, including a letter of explanation for any billing or processing errors. 

Use the ADR Tool

Medicare contractors typically provide an ADR tool to determine what documents are needed and why they were requested. The ADR tool also provides information on who requested the additional documentation and educational information on properly billing similar claims. 

Pay Attention to Details

ADR letter responses are easy in theory and complicated in practice, but paying attention to response submission requirements will result in better reimbursement outcomes. A supplier should not omit a response to particular request or send original documentation. Keep a copy of your response—it may be useful as you prepare your appeal.

R. Ross Burris, III and Matthew Agnew, who contributed to this article, are attorneys at Polsinelli PC. Reach them at or