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How to appeal Medicare or Medicaid overpayment determinations

In recent years, federal authorities have been making an effort to prevent fraud, waste and abuse within the Medicare and Medicaid programs. As a result, health care businesses of all types and sizes are being accused of overpayments.

If you have received a letter from Health Integrity, the Office of the Inspector General or Connolly alleging that your business received incorrect payments from Medicare or Medicaid, then you may decide to dispute the determination. It is essential to have an experienced attorney on your side throughout the appeals process.

How does the overpayment appeals process work?

The appeals process is the same for all health care providers, from solo practitioners to large medical equipment suppliers. There are five possible levels of appeal that may take place, including:

  • Redetermination (Level 1): You ask the Medicare contractor that made the overpayment determination to look at the determination again. After the contractor reexamines the determination, a decision will be provided in writing, either changing the determination or denying the claim.
  • Reconsideration (Level 2): If the first appeal is denied, you may ask a qualified independent contractor (QIC) to review the determination. The QIC is selected by the Centers for Medicare and Medicaid Services (CMS), and it is the last opportunity you have to submit new evidence backing your claim.
  • OMHA ALJ Hearing (Level 3): If you are not happy with the outcome at Level 2, you may request to have a hearing that includes witness testimony, much like a civil trial. An administrative law judge (ALJ) from the Office of Medicare Hearings and Appeals (OMHA) presides and issues a finding.
  • Medicare Appeals Council (Level 4): If you are not happy with the ALJ’s decision, then you may file a written appeal with the Medicare Appeals Council.
  • Federal District Court (Level 5): You have one final chance for appeal by filing a lawsuit is in federal district court.

How an experienced attorney can help you through the process

At Rivas Goldstein LLP, we provide comprehensive representation to medical providers and suppliers accused of overpayment. That means we are there to offer our knowledge and stand up for your legal rights from the initial Health Integrity investigation through a Federal District Court appeal, if necessary.

We take a strategic approach to every case, analyzing the techniques used by the Medicare contractor and exploring legal and factual grounds for appeal. By taking this thorough approach, we have been very successful at recovering significant funds for our clients.

Most medical providers and suppliers are accused of Medicare or Medicaid overpayment at some point, but it is still important to take the matter seriously and act quickly if you wish to appeal the determination and recover funds that rightfully belong to your business.