Tag: ALJ Appeals

AMARILLO, Texas – Provider Josh Britten appealed $650,000 worth of denied Medicare claims back in 2015 and it took him six years and more than $100,000 to get it back. And he’s one of the lucky ones – he had the resources to stick with it.  “We filed our third appeal in 2015 and we finally received a decision in 2021,” said Britten, CEO of BritKare Home Medical. “We were six years waiting on a decision (at the ALJ level) that should have taken 90 days.”  Here’s...

WASHINGTON - The Office of Medicare Hearings and Appeals is back to operating at full capacity and is making its way through a backlog of appeals at the Administrative Law Judge level, AAHomecare reports. As of Oct. 31, 2020, there are about 85,000 DMEPOS appeals pending at the ALJ, a decrease of 51% compared to nearly 173,000 in 2019. OMHA also reported that the average wait time for an ALJ hearing is still four years, but it believes that should decrease as judges work their way through the backlog....

MIAMI - Matthew Fischer, a former senior attorney adviser for the Office Medicare Hearings and Appeals, has seen the ugliness of the appeals backlog from the inside. Here's what Fischer, now an attorney with the Zumpano Patricios, had to say about how to work a flawed system.HME News: What did the appeals system look like from the inside?Matthew Fischer: When I got there in 2011, I'd be looking at cases from two or three years ago. I thought, what is going on? They just didn't have the resources...

WASHINGTON - CMS has rolled out a new settlement option for low-volume appeals, but it's not likely HME providers will take the agency up on its offer, stakeholders say.Providerswith fewer than 500 appeals pending at the Office of Medicare Hearings and Appeals and the Medicare Appeals Council combined as of Nov. 3, 2017 with a total billed amount of $9,000 or less per appeal could be eligible, if certain other conditions are met.The kicker: CMS will settle eligible appeals at 62% of the net allowed...

WASHINGTON - CMS recently announced a low volume appeals settlement for Part A and Part B appeals at the Office of Medicare Hearings and Appeal and the Medical appeals Council. The option is limited to appellants with less than 500 appeals and each individual appeal must total $9,000 or less. The settlement is for 62% of the allowed amount minus the copay, according to a bulletin from AAHomecare. As of August 2017, OMHA had 591,962 total appeals pending—an increase of 300% since 2016. The number...

A. If CMS or a supplier disagrees with an Administrative Law Judge's (ALJ) decision, the matter may be appealed to the Departmental Appeals Board (DAB). But, as many suppliers know, the DAB appellate process is substantially backlogged, although it is not as backlogged as the Office of Medicare Hearings and Appeals. This article will focus on tips and tricks designed to help the DAB efficiently dispose of your matter and render a quick decision (hopefully in your favor).Make the decision easyMaking...

A. A supplier that disagrees with a Qualified Independent Contractor's reconsideration decision is entitled to a hearing before an administrative law judge. But, an ALJ will not review new evidence—evidence that was not presented during previous levels of appeal without the supplier presenting “good cause.” The ALJ will not review any new evidence unless that evidence was unavailable or unknown at the time of the determination.Oftentimes, suppliers rely on the documentation submitted...

A. If you find yourself in the unfortunate position of having to submit a Medicare request for redetermination or reconsideration, make sure that you are thoughtful in your submission and that you pay attention to the details provided in the overpayment demand.Redetermination Redetermination requests must comply with regulatory deadlines—the request must be submitted within 120 days of receipt of the initial determination or filed within 30 days to stay recoupment, and the Medicare Administrative...

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 AttorneyInvolving an attorney at the ADR letter stage is not always necessary, but a response that does not provide adequate...

WASHINGTON - The Office of Medicare Hearings and Appeals (OMHA) has announced a pilot program aimed at helping providers resolve claims appealed to the administrative law judge (ALJ) level.The OMHA earlier this year held a hearing to address the huge backlog of appeals at the ALJ level.To qualify for the program, a provider must have a minimum of 20 claims or $10,000 tied up in appeals. The amount of each claim must be less than $100,000.Other requirements of eligibility: Claims must have been filed...