RESPONSES FOR ALJ APPEALS FOR MEDICARE CLAIMS
Amanda Springer
Description
Collection
Title:
RESPONSES FOR ALJ APPEALS FOR MEDICARE CLAIMS
Creator:
Amanda Springer
Date:
1/28/2013
Text:
Thanks you all for your responses. I have been asked to share the information I received. Please feel free to continue to update me on your progress with the ALJ and I will do the same!
Amanda
1.) In mid-2009, we received an Rx from a doctor to fabricate a new lower limb prosthesis for a long time patient. The patient had lost a fair amount of weight and consequently the socket fit was no longer adequate. This patient was a K-3/K-4 ambulator and very active. We fabricated and delivered the prosthesis to the patient, billed Medicare and were reimbursed in 2009.
In mid 2012, nearly 3 years after delivery and payment for this prosthesis, we received a letter from Medicare indicating that they were denying our claim for the Flex-Walk system (L5981) based on lack of documentation for the patient's functional level. How Medicare made this determination is beyond me as the only information submitted to Medicare was the 1500 claim form. We have never been asked or required to submit any additional documentation for claims processing. We immediately appealed the decision, requesting a redetermination and submitting a letter regarding the patient's functional level.
One problem we had was that our patient records files prior to 2010 were woefully inadequate. One of the things I did after acquiring the practice was to implement the policies and procedures necessary to achieve Facility Accreditation with ABC, which we received in December 2010. Our patient files for this patient had no clinical notes from the CPO and only contained a copy of the doctor's prescription.
Our request for redetermination was ruled unfavorable so we requested a review by a Qualified Independent Contractor (QIC). This review was also returned unfavorable and Medicare sustained their demand for recoupment of nearly $2,500 for the amount paid plus interest. Medicare used this claim to offset approved payments for two other Medicare patients for claims that were processed during this appeal time period. I made several attempts to contact the patient's doctor who had prescribed the prosthsis in 2009 (the patient had changed doctors). I was finally able to reach the doctor and asked him to provide a letter attesting to the patient's need for a new prosthesis and his functional level. Unfortunately, we did not receive this letter from the doctor until after we had to submit the request for the QIC and risk losing our right to appeal based on time.
During this appeal process, we received another letter from Medicare indicating that, as a result of the review by the QIC review, Medicare was now denying the remainder of the claim (aproximately $5,000) based on their determination that medical necessity was not established!
After the unfavorable QIC ruling we pursued our last option which was to request a review by an Administrative Law Judge (ALJ Review). We received confirmation of our request for an ALJ Review in November and were told they had something like 160 days to schedule the review. In December we did learn that our appeal had been assigned to a particular judge and that our case would be calendared in late January or early February. The paperwork we submitted for the ALJ review included the letter from the patient's doctor attesting to his need for the prosthesis as well as his functional level. It also included (again) a copy of the Rx and a copy of the doctor's notes from the patient visit in which the doctor determined he required a new prosthesis. We also included copies of our previous letters sent with earlier stage appeals.
On Tuesday, January 22, 2013, we received a letter from Medicare indicating that the Administrative law Judge had reviewed our appeal prior to scheduling the hearing and had rendered a decison: WHOLLY FAVORBLE TO THE APPELLANT and ordering Medicare to reimburse our practice for the recoupment thay had received on the denial of L5981, plus any interest assessed. This was obviously fantastic news that we had prevailed in our appeal.
I am optimistic that following the favorable ruling we received, Medicare will reverse their request for recoupment on the balance of the claim for this prosthesis and will no longer pursue refund of the $5,000 for the balance of the claim. It would be hard for me to imagine that Medicare could uphold denial for part of a claim when another part of the claim had already been determined to be valid on the basis of medical necessity and functional level.
So, my advice based on my personal experience is this: take advantage of all available appeal opportunities if you believe your claim has been denied for invalid reasons. Even if you lack the necessary evidence in file to suport your position, do whatever you can to obtain the necessary information after the fact, even if it means tracking down doctors, requesting copies of the doctor's medical records for the patient, practitioners, etc. who may have been involved in the case
2.) We just went through an ALJ phone trial but have not yet received the result after about a month. I can tell you it took over a year from filing appeal to court date. The good news is the judge seemed very reasonable, logical and unbiased.
3.)Had to go through an ALJ a few years ago over a socket. We won. You won’t have any problem as long as your clinical doc is in order. If you have made reasonable but unsuccessful attempts at getting Dr. notes you still should be ok.
4.)We are in a similar scenario as are most others. We sent a letter to our ALJ requesting more information about our hearing date and they called back within 2 weeks
5.)My understanding is that the ALJ is supposed to hear your case within 90 days, but they are severely backed up, as you may well imagine. My advice is to always appeal all the way to the ALJ always ask for an telephone hearing with the ALJ know your LCD's and coverage criteria Our denials have so far always been overturned by the ALJ.
6.)We have one we filed on june 16th we sent another letter in November after not hearing and anything. We just got it scheduled February 20th on work i did two years ago.
Amanda
1.) In mid-2009, we received an Rx from a doctor to fabricate a new lower limb prosthesis for a long time patient. The patient had lost a fair amount of weight and consequently the socket fit was no longer adequate. This patient was a K-3/K-4 ambulator and very active. We fabricated and delivered the prosthesis to the patient, billed Medicare and were reimbursed in 2009.
In mid 2012, nearly 3 years after delivery and payment for this prosthesis, we received a letter from Medicare indicating that they were denying our claim for the Flex-Walk system (L5981) based on lack of documentation for the patient's functional level. How Medicare made this determination is beyond me as the only information submitted to Medicare was the 1500 claim form. We have never been asked or required to submit any additional documentation for claims processing. We immediately appealed the decision, requesting a redetermination and submitting a letter regarding the patient's functional level.
One problem we had was that our patient records files prior to 2010 were woefully inadequate. One of the things I did after acquiring the practice was to implement the policies and procedures necessary to achieve Facility Accreditation with ABC, which we received in December 2010. Our patient files for this patient had no clinical notes from the CPO and only contained a copy of the doctor's prescription.
Our request for redetermination was ruled unfavorable so we requested a review by a Qualified Independent Contractor (QIC). This review was also returned unfavorable and Medicare sustained their demand for recoupment of nearly $2,500 for the amount paid plus interest. Medicare used this claim to offset approved payments for two other Medicare patients for claims that were processed during this appeal time period. I made several attempts to contact the patient's doctor who had prescribed the prosthsis in 2009 (the patient had changed doctors). I was finally able to reach the doctor and asked him to provide a letter attesting to the patient's need for a new prosthesis and his functional level. Unfortunately, we did not receive this letter from the doctor until after we had to submit the request for the QIC and risk losing our right to appeal based on time.
During this appeal process, we received another letter from Medicare indicating that, as a result of the review by the QIC review, Medicare was now denying the remainder of the claim (aproximately $5,000) based on their determination that medical necessity was not established!
After the unfavorable QIC ruling we pursued our last option which was to request a review by an Administrative Law Judge (ALJ Review). We received confirmation of our request for an ALJ Review in November and were told they had something like 160 days to schedule the review. In December we did learn that our appeal had been assigned to a particular judge and that our case would be calendared in late January or early February. The paperwork we submitted for the ALJ review included the letter from the patient's doctor attesting to his need for the prosthesis as well as his functional level. It also included (again) a copy of the Rx and a copy of the doctor's notes from the patient visit in which the doctor determined he required a new prosthesis. We also included copies of our previous letters sent with earlier stage appeals.
On Tuesday, January 22, 2013, we received a letter from Medicare indicating that the Administrative law Judge had reviewed our appeal prior to scheduling the hearing and had rendered a decison: WHOLLY FAVORBLE TO THE APPELLANT and ordering Medicare to reimburse our practice for the recoupment thay had received on the denial of L5981, plus any interest assessed. This was obviously fantastic news that we had prevailed in our appeal.
I am optimistic that following the favorable ruling we received, Medicare will reverse their request for recoupment on the balance of the claim for this prosthesis and will no longer pursue refund of the $5,000 for the balance of the claim. It would be hard for me to imagine that Medicare could uphold denial for part of a claim when another part of the claim had already been determined to be valid on the basis of medical necessity and functional level.
So, my advice based on my personal experience is this: take advantage of all available appeal opportunities if you believe your claim has been denied for invalid reasons. Even if you lack the necessary evidence in file to suport your position, do whatever you can to obtain the necessary information after the fact, even if it means tracking down doctors, requesting copies of the doctor's medical records for the patient, practitioners, etc. who may have been involved in the case
2.) We just went through an ALJ phone trial but have not yet received the result after about a month. I can tell you it took over a year from filing appeal to court date. The good news is the judge seemed very reasonable, logical and unbiased.
3.)Had to go through an ALJ a few years ago over a socket. We won. You won’t have any problem as long as your clinical doc is in order. If you have made reasonable but unsuccessful attempts at getting Dr. notes you still should be ok.
4.)We are in a similar scenario as are most others. We sent a letter to our ALJ requesting more information about our hearing date and they called back within 2 weeks
5.)My understanding is that the ALJ is supposed to hear your case within 90 days, but they are severely backed up, as you may well imagine. My advice is to always appeal all the way to the ALJ always ask for an telephone hearing with the ALJ know your LCD's and coverage criteria Our denials have so far always been overturned by the ALJ.
6.)We have one we filed on june 16th we sent another letter in November after not hearing and anything. We just got it scheduled February 20th on work i did two years ago.
Citation
Amanda Springer, “RESPONSES FOR ALJ APPEALS FOR MEDICARE CLAIMS,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 1, 2024, https://library.drfop.org/items/show/234578.
