Medicare Appeals — Filings with the Office of Medicare Hearings and Appeals Switch to a Central Docketing System.

(March 1, 2012):  Medicare appeals of denied claims arising out of audits conducted by Zone Program Integrity Contractors (ZPICs) and Recovery Audit Contractors (RACs) has significantly increased as administrative enforcement efforts have expanded around the country.  While workloads have generally risen across the board, the number of cases handled from one ZPIC to another has resulted in an enormous disparity in workload for the various Field Offices of the Office of Medicare Hearings and Appeals (OMHA).

I.     Medicare Appeals Will Now be Handled Through a “Central Docketing System”:

As a result, OMHA recently switched to a “Central Docketing System” for all pending and new Medicare appeals. Under this new system, all Administrative Law Judge (ALJ) hearing requests will initially be sent to OMHA’s Central Office in Cleveland, OH. Each appeal will subsequently be assigned to one of the Field Offices – Irvine,  CA, Miami, FL or Arlington, VA – or to ALJs in the Central Office, depending on the caseload in each office. Despite assigning appeals to different offices, OMHA is not breaking these appeals into their component parts – individual claims –  so “big box” cases will still be handled by one ALJ.

While each Medicare appeal will likely be assigned to an office randomly, OMHA will likely base these assignments on current workloads at each of its offices. Therefore, a provider in Texas or Louisiana, who would previously have always gone before an ALJ in the Miami Field Office, may end up before an ALJ in any of OMHA’s four offices. While this may be disconcerting at first, most ALJ hearings are conducted by phone or video-teleconference nowadays, meaning that the ALJ’s location doesn’t substantially affect how a case is handled. While it may be more difficult to ascertain the procedural habits of a single ALJ (such as in what order to present information or how formal each hearing session is) since you and/or your counsel may go before a wider array of ALJs, Medicare appeals and hearings should generally be handled in the same manner.

II.     Responding to a Medicare Overpayment Audit / Filing a Medicare Appeal:

Years ago, it was not uncommon for physicians or members of their staff to represent a practice in a hearing before an ALJ.  Unfortunately, those days are long past.  While representing ones-self in an ALJ hearing may still be an option in hearings involving a limited number of claims, if the amount in controversy is substantial, there is a high likelihood that one or more representative of the ZPIC will show up at the ALJ hearing and give their reasons for denying the claims at issue.  Although the ALJ hearing process is not meant to be adversarial, it often feels like a contested hearing when representatives from a ZPIC or another Medicare contractor choose to participate in the proceeding.  Are you prepared to respond to their assertions?  If not, it is important to retain qualified and experienced legal counsel to assist you in the matter.

Liles Parker is a full service health law firm with several offices around the country. Representing providers in all stages of Medicare post-payment appeals, our attorneys are well-versed in the administrative appeals process and capable of aggressively handling your case. In addition, we conduct compliance program advising and implementation, as well as mock audits, staff training and health care business transactions. Please call Robert W. Liles at:  1 (800) 475-1906 for a complimentary consultation today.