Medicare Administrative Appeal Legal Update

Successful Medicare Administrative Appeal Creates Substantial Reduction to PSC Reimbursement Charge for Client

Stephen D. Barham    Joy Dixon Wilman      Katherine M. Block

The Medicare Administrative Appeals Team at Chambliss, Bahner & Stophel recently scored a major victory for a client that had received a program safeguard contractor (“PSC”) audit.  The client’s billing company handled the initial Medicare appeals process and found little success.  After the initial appeal, the client was advised it owed over $400,000 for overpayments to Medicare.  Working closely with the client, the CB&S Medicare Appeals Team appealed the audit determinations - specifically the proper coding level for the services rendered by the client -- to the Administrative Law Judge (“ALJ”).

The PSC had narrowly interpreted the requirements to meet the billing code standards resulting in significant write-downs on billing submissions.  Through the appeal our team was able to establish that the majority of the claims found to be coded in error were in fact properly billed.  At the conclusion of the matter, the ALJ’s reversal of a substantial number of individual billing reviews caused the client to slip below the threshold which justified extrapolation of the audit findings.  By avoiding extrapolation, we reduced the client’s debt owed to Medicare from more than $400,000 to less than $1,500.

If you or your practice receives an inquiry or billing audit from a Medicare contractor and you have any questions regarding how best to proceed in regard to this audit, please do not hesitate to contact Steve Barham, Joy Wilman or Kathy Block.  We would be glad to help you through any part of the process from the initial response through any administrative appeal reviews.