Representing Texas Health Care Providers In Medicare Overpayment Appeals
At some point, nearly every health care provider, from solo practitioners to home health agencies to large medical equipment suppliers, will receive incorrect payments from Medicare or Medicaid, the two largest federal payors.
At Rivas Goldstein, LLP, we represent Texas health care providers wishing to appeal alleged Medicare overpayments. Our attorneys provide comprehensive representation in overpayment matters, from dealing with Health Integrity investigations through handling all stages of an overpayment appeal.
The success rate for Rivas Goldstein, LLP, attorneys exceeds 90% in payments of previously denied claims. In addition, our attorneys have recovered well over $8 million via the Medicare appeals process.
How Are Overpayment Determinations Made?
The government contracts with a number of entities who have authority to make overpayment determinations. Some of these include Recovery Audit Contractors (RAC), Medicaid Integrity Contractors (MIC), Health Integrity, and Medicare Administrative Contractors (A/B/MAC).
How Does The Appeal Process Work?
Whether the overpayment is initiated by the carrier, a MIC, MAC or other entity, the Medicare appeals process is the same. The process is the same for all health care providers, from doctors to home health agencies to suppliers. There are five possible levels of appeal. Our Austin lawyers are able to represent clients at any and all of these levels:
- Level 1 — Redetermination: At this stage, the provider asks the Medicare contractor to take a second look at the overpayment. The contractor will provide a written decision either changing the determination or denying the claim. If the claim is denied, go to level two.
- Level 2 — Reconsideration: Here, Medicare overpayment appeals are assessed by a qualified independent contractor (QIC) chosen by the Centers for Medicare and Medicaid Services (CMS). Legal counsel is valuable at this level because it is the last chance for a provider to submit new documentation to challenge the overpayment.
- Level 3 — OMHA ALJ Hearing: Providers who are not satisfied with the outcome of reconsideration can request a hearing before an administrative law judge (ALJ) at the Office of Medicare Hearings and Appeals (OMHA). This process includes witness testimony, much like a civil lawsuit.
- Level 4 — Medicare Appeals Council (MAC): If the ALJ decision is not satisfactory to the provider, the matter can be taken to the MAC. This is an entirely written appeal. Our attorneys can handle the entire proceeding on your behalf.
- Level 5 — U.S. District Court: The last avenue of appeal for providers and suppliers is to file a lawsuit is in federal court.
Experience You Can Trust
The health care law team at Rivas Goldstein, LLP, has the collective knowledge, experience and resources needed to see an overpayment appeal through to its completion. We thoroughly analyze the situation, including the error rates extrapolation techniques used by the contractor. We look strategically at each case, testing the legal and factual bases for the overpayment determination.
We attend all hearings, ensuring that our clients have the opportunity to clear the record. We also undertake negotiations to reduce the amount a client owes in fines or reimbursements for alleged overpayments.