Reimbursement Audits and Appeals

We understand how to navigate the administrative appeals and voluntary disclosure processes and provide critical guidance on audits and investigations.

Overview

As the healthcare industry continues to grow and health care costs continue to rise, health care providers face increased scrutiny from the Centers for Medicare & Medicaid Services and their contractors, as well as other federal and state agencies. We advise clients on a broad range of regulatory and reimbursement issues, from evaluating appropriate billing practices to handling pre- and post-payment audits, including UPIC, RAC and state Medicaid audits. In addition, hospital, nursing home, home health, hospice and other health care clients benefit from the firm’s extensive experience with navigating the administrative appeals process and voluntary disclosure process, at the federal and state level.

Our specialties include counseling clients through challenging statistical sampling and extrapolation, medical record review and organization to respond to additional documentation requests, the navigation of the various settlement initiatives for providers caught in the appeals backlog, and responding to litigation-related TROs.

Experience

  • Successfully represented a Georgia home health provider in a request for reconsideration of a CMS contractor’s decision to terminate the provider’s Medicare enrollment.
  • Represented a national home health provider to appeal over 1,000 claims denied under pre-payment review for medical necessity and successfully overturned many denials at the Re-determination and Reconsideration stages of appeal.
  • Represented a Georgia skilled nursing facility provider to appeal rehabilitation claims denied for technical issues and successfully overturned 94% of the denials at the Re-determination and Reconsideration stages of appeal.
  • Represented a national inpatient rehabilitation and long-term care hospital provider over 200 Administrative Law Judge (ALJ) appeals and successfully overturned many denials through on-the-record decisions and in ALJ hearings.

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