ALJ vindicates bankrupt HME

Friday, February 28, 2003

RALEIGH, N.C. - Almost four years and thousands of dollars later, Paul Smith can finally breathe a sigh of relief.
After a long legal battle with Palmetto GBA, the Medicare carrier for Region C, an administrative law judge heard Smith’s appeal in January and overruled the decision claiming he owed the Medicare carrier more than $71,000. Palmetto now has 60 days upon the decision to appeal or pay Smith $12,500 for the claims approved after his suspension.

“I feel vindicated,” said the 60-year-old who was forced to close the doors of Piedmont Mobility in 2000 due to the claims. “It’s like a breath of fresh air. Now I’m going to start over - start over in a big hole.”

In 1999 Piedmont Mobility’s revenues hit $2.5 million and Palmetto began looking into the power chair business. After four audits over two-years, Smith was accused of providing wheelchairs without ordering physicians and medical necessity. Palmetto stopped payment and claimed he owed $59,000, without interest. The carrier had already withheld about $12,000. After a carrier hearing in which Smith said Palmetto changed its tune and began attacking the delivery dates of the 16 claims in question instead of lack of ordering physician and medical necessity, he appealed his case to an ALJ. After almost five months, the ALJ finally ruled against all 16 counts.

“We can not comment on one of our providers under the privacy act,” said Elizabeth Nkuo, corporate communications for Blue Cross Blue Shield of South Carolina, Palmetto’s parent company.

Major changes are needed to the audit process, Smith said, beginning with an appeal to the CMS and HHS for another Region C carrier.“The first thing I’m going to do is get Palmetto’s contract pulled,” he said. “They have no business providing their service for the government.” HME