ALJ

Amniotic Fluid / Amniotic Membrane Tissue Audits, Investigations and Prosecutions are Continuing to Climb in 2022

(August 4, 2022): Over the past year, we have seen a significant increase in the number of Medicare administrative audits, False Claims Act investigations and criminal prosecutions by the Department of Justice (DOJ), related to the billing of allogeneic (harvested from someone else) stem cell products. Medicare and Medicaid claims stemming from amniotic liquid and […]

Amniotic Fluid / Amniotic Membrane Tissue Audits, Investigations and Prosecutions are Continuing to Climb in 2022 Read More »

HHS Issues Final Rule to Address Record High Medicare Appeals Backlog

(January 20, 2017): The Medicare appeals backlog has reached its all-time worst. If you’re a healthcare provider or supplier waiting for a hearing before an Administrative Law Judge (ALJ) at the Office of Medicare Hearings and Medicare Appeals (OMHA) – the third level of the Medicare appeals process – you’ve likely been waiting years to

HHS Issues Final Rule to Address Record High Medicare Appeals Backlog Read More »

CMS Seeks to Overhaul Medicare Claims Appeal Process

(July 18, 2016): The Centers for Medicare and Medicaid Services (CMS) has announced a series of proposed changes to the Medicare claims appeal process. The new rules primarily impact the Administrative Law Judge (ALJ) level of review, and CMS has indicated that the purpose of these changes is to help reduce the backlog of pending

CMS Seeks to Overhaul Medicare Claims Appeal Process Read More »

CMS Expands ALJ Appeal Claim Settlement Process to Include Part A Providers

(April 4, 2016) In an effort to reduce the enormous backlog of pending Administrative Law Judge (ALJ) appeals, the Centers for Medicare and Medicaid Services (CMS) recently announced that it has expanded the pilot Settlement Conference Facilitation (SCF) process to include Part A claims. This process, which was previously only available to providers with pending

CMS Expands ALJ Appeal Claim Settlement Process to Include Part A Providers Read More »

CMS Issues New Instructions to its Contractors Regarding the Scope of Claim Appeals

(October 15, 2015): In an effort to stem the ever-increasing tide of claim appeals, CMS recently issued new guidance (MLN Matters SE1521) to its Medicare Administrative Contractors (MACs) and Qualified Independent Contractors (QICs) regarding the conduct of requests for redetermination and reconsideration, respectively. Effective 08/01/15, MACs and QICs may no longer review claims denied during

CMS Issues New Instructions to its Contractors Regarding the Scope of Claim Appeals Read More »

The Medicare Appeals Process is Broken

(May 5, 2015): As the health care providers and suppliers we represent can easily attest, there are serious problems plaguing the current Medicare appeals process. Rubber-stamp denials by contractors[1] at lower levels of appeal, the failure of Medicare contractors to apply the correct coverage rules and requirements when assessing a claim, and lengthy delays in

The Medicare Appeals Process is Broken Read More »

Medicare Administrative Appeals Process – An Overview for New Providers

(August 15, 2012): Is this your first time being audited by a Medicare Administrative Contractor (MAC) or a Zone Program Integrity Contractor (ZPIC)? If so, the brief outline below can provide a handy summary of the Medicare appeals process. I. Step 1 – Request for Information: In most instances, a health care provider will receive

Medicare Administrative Appeals Process – An Overview for New Providers Read More »

OMHA Changes ALJ Hearing Case System

(March 2, 2012): Likely recognizing the enormous disparity in Administrative Law Judge (ALJ) hearing workloads for its various Field Offices, the Office of Medicare Hearings and Appeals (OMHA) recently switched to a Central Docketing System for all pending and new appeals. Under this new system, all ALJ hearing requests will be sent to OMHA’s Central

OMHA Changes ALJ Hearing Case System Read More »

Are Medicare ALJs Truly Independent Fact Finders?

(February 20, 2011): Over the years, we have represented a wide variety of health care providers in the administrative appeals process. Our duties have regularly included representation before Administrative Law Judges (ALJs) presiding out of the Western, Southern, Midwestern and Mid-Atlantic Field Offices of the Office of Medicare Hearings and Appeals. (OMHA). In the course

Are Medicare ALJs Truly Independent Fact Finders? Read More »

ZPIC Participation in ALJ Hearings is Increasing

(February 12, 2011): Over the last year, we have noted an important trend when representing Medicare providers in post-payment overpayment cases at the Administrative Law Judge (ALJ) level of appeal. Medicare contractors are actively attending and participating in many ALJ hearings. In fact, it is now common for a Zone Program Integrity Contractor (ZPIC) to

ZPIC Participation in ALJ Hearings is Increasing Read More »