Medicare Appeals

The Health Law Firm and its legal professionals represent health care providers in virtually every aspect of Medicare Program, including audits, probes, investigations, fair hearings, administrative hearings, and litigation. These include physicians, medical groups, mental health professionals, pharmacies, durable medical equipment (DME) suppliers, nursing homes, home health agencies, hospitals and other health facilities.

It is extremely important that the health care provider obtain experienced professional representation in responding to a Medicare Program audit notice. There are many problematic legal issues that a Medicare audit seeks to identify in such audits. Each year the Office of the Inspector General (OIG) publishes a list of the types of procedures, types of health care professionals, and specific medical services and specific billing codes it will concentrate on for the coming year. It is extremely important that the correct responses to the auditors be made, as well as the provision of complete, legible, well-organized, responsive medical records (and other supporting documentation) must be provided, which support each code that has been billed to the program. This is crucial from the very beginning.

We have experience in dealing with the Medicare Program’s carriers, fiscal intermediaries, procurement integrity agents, and special investigators.

Even after receipt of a demand for an overpayment that may be alleged to be due to the Medicare Program (in Florida, administered by First Coast Service Options, Inc., for Part B providers or by Palmetto Government Benefits Administrators, Inc. (Palmetto GBA) for DME suppliers, it may still be possible to negotiate a repayment or settlement of the matter on favorable terms. If not, then The Health Law Firm and its attorneys are experienced in representing the health care provider in appeals of payment decisions, carrier fair hearings, formal administrative hearings, in civil litigation or in appeals on such matters.

For a copy of an appeal decision from the Centers for Medicare and Medicaid Services (CMS) in a case in which we represented a DME supplier, click here.

In the event that a health care professional receives a subpoena or search warrant for records concerning a Medicare criminal investigation, our attorneys are experienced in dealing with OIG special agents, FBI agents, and Assistant U.S. Attorneys in attempting to resolve the case before criminal charges are filed.

We also assist providers in obtaining Medicare and Medicaid provider status (provider identification numbers), as well as, in proceedings seeking to revoke or terminate a health care provider’s Medicare and Medicaid provider status. We advise clients on performing internal audits of Medicare and Medicaid services, billing, reimbursement and on how to make voluntary refunds of overpayments to the Medicare and Medicaid Progams.