ALJ Update
Sara Beck
Description
Collection
Title:
ALJ Update
Creator:
Sara Beck
Date:
3/29/2013
Text:
I wanted to give some insight and encouragement with regards
to an ALJ level hearing for a Medicare audit. I have received a lot of phone calls and emails about the ALJ level and
some providers are very anxious and nervous to appeal to that level. I have had several ALJ appeals overturned
without even having a hearing. But,
yesterday I had my first telephone hearing with an ALJ. The hearing lasted merely 5 minutes. The judge had a hard time understanding what
the issue with the claim was, and that was his reason for wanting an actual
hearing. He continued to say that my
documentation was more than sufficient and could not understand why Medicare
continued to deny it. It was refreshing
to hear. It was noted that Medicare
continued to deny the appeal because there were “no physician notes in patient’s
medical record.” However, the Judge
continued to say that physician notes were not required. He also mentioned that his office gets 5,000
appeals every week! He said the ALJ’s
could not handle this much longer because that number continues to
increase. These judge’s are very much
aware of the problems with Medicare’s audits and I got the feeling that they
are getting fed up as well.
Also, Medicare sent a very pretentious letter to me last
week stating they will be involved in the hearing and will be arguing their
case. A CMS physician was supposed to
present at the hearing to provide their defense. But, she was a no-show. So, if you get notice that CMS will be involved
in the hearing, don’t let it stop you. It is just an attempt to intimidate and deter you from going through
with the hearing. I was actually looking
forward to speaking with CMS and questioning her about their tactics.
Moral of the story, keep appealing! It is working. One word of advice when you get to the ALJ
level, make sure you personalize the appeal. Tell the judge your patient’s story and ask the judge if taking back the
money earned by you is a just result. ALJ’s have to come to a fair conclusion ahead of any policy rules or
guidelines. If you explain to the judge
that your patient received the services that were billed and greatly benefitted
from them, then taking your legitimately earned money for those services is
unjust and prejudicial. An
administrative law judge will not think that withholding money for services
provided is justified. In fact, it’s
unjust enrichment. Medicare, their
contractors and the patient all receive a benefit at your expense.
Also, I have been in touch with the Senator for my
state. It has been a struggle because
she continues to claim there is nothing she can do. But, I know that is not the case. So, keep pressuring the senate and your
representatives, we will eventually get through and find a solution. But, they have to get enough complaints to
take action.
Please contact me with any questions or concerns,
Sara Beck
San Joaquin Orthotics & Prosthetics
to an ALJ level hearing for a Medicare audit. I have received a lot of phone calls and emails about the ALJ level and
some providers are very anxious and nervous to appeal to that level. I have had several ALJ appeals overturned
without even having a hearing. But,
yesterday I had my first telephone hearing with an ALJ. The hearing lasted merely 5 minutes. The judge had a hard time understanding what
the issue with the claim was, and that was his reason for wanting an actual
hearing. He continued to say that my
documentation was more than sufficient and could not understand why Medicare
continued to deny it. It was refreshing
to hear. It was noted that Medicare
continued to deny the appeal because there were “no physician notes in patient’s
medical record.” However, the Judge
continued to say that physician notes were not required. He also mentioned that his office gets 5,000
appeals every week! He said the ALJ’s
could not handle this much longer because that number continues to
increase. These judge’s are very much
aware of the problems with Medicare’s audits and I got the feeling that they
are getting fed up as well.
Also, Medicare sent a very pretentious letter to me last
week stating they will be involved in the hearing and will be arguing their
case. A CMS physician was supposed to
present at the hearing to provide their defense. But, she was a no-show. So, if you get notice that CMS will be involved
in the hearing, don’t let it stop you. It is just an attempt to intimidate and deter you from going through
with the hearing. I was actually looking
forward to speaking with CMS and questioning her about their tactics.
Moral of the story, keep appealing! It is working. One word of advice when you get to the ALJ
level, make sure you personalize the appeal. Tell the judge your patient’s story and ask the judge if taking back the
money earned by you is a just result. ALJ’s have to come to a fair conclusion ahead of any policy rules or
guidelines. If you explain to the judge
that your patient received the services that were billed and greatly benefitted
from them, then taking your legitimately earned money for those services is
unjust and prejudicial. An
administrative law judge will not think that withholding money for services
provided is justified. In fact, it’s
unjust enrichment. Medicare, their
contractors and the patient all receive a benefit at your expense.
Also, I have been in touch with the Senator for my
state. It has been a struggle because
she continues to claim there is nothing she can do. But, I know that is not the case. So, keep pressuring the senate and your
representatives, we will eventually get through and find a solution. But, they have to get enough complaints to
take action.
Please contact me with any questions or concerns,
Sara Beck
San Joaquin Orthotics & Prosthetics
Citation
Sara Beck, “ALJ Update,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 2, 2024, https://library.drfop.org/items/show/234779.
