Thursday, June 23, 2011

Q. What can I do differently at an administrative law judge (ALJ) hearing?

A. The ALJ hearing process normally affords providers a greater opportunity to present evidence, arguments and witnesses in support of payment. Many ALJs are open to listening to the provider's verbal arguments. Understanding the ALJ process can increase the provider's chances of receiving a favorable decision. In addition to retaining experienced legal counsel, providers should have a clinician testify telephonically in support of the claim(s).

CMS attorneys will argue that providers cannot submit additional evidence to the ALJ because of the rules of evidence. According to CMS HHS S422.1048, the ALJ may receive evidence at the hearing even though the evidence is not admissible in court under the rules of evidence used by the court. The ALJ rules on the admissibility of the evidence.

Step 1:  Request additional medical records to support medical necessity. Be prepared to explain to the ALJ why these new records were not submitted with the initial appeals. 

Step 2:  Hire a clinician to review the patient file and testify at the hearing. If you or your attorney can't hire a clinician with hearing experience, you should request the referring provider to testify in support of his/her prescription.

Step 3:  Request that the ALJ issue a subpoena for the physician to make medical records available for inspection and copying, and/or for the physician's appearance and testimony when the medical records or testimony are material to an issue at the hearing. The appearance and testimony of witnesses can be given by telephone or video teleconferencing.

Unfortunately a favorable ALJ ruling is still subject to review by the Administrative Qualified Independent Contractor, which may request additional review.

Be different. Have a witness.

Cheryl Ward is CEO of Agape Medical Management. She can be reached at 951-680-1640 or