Category Archives: Medicare Reimbursement

18 Oct

Changes to the Amount in Controversy Thresholds for Medicare Appeals

Beginning on or after January 1, 2020, the amount in controversy needed by Medicare providers will change as follows: $170 for Administrative Law Judge (ALJ) hearings. (2019 – $160) $1,670 for judicial review (2019 – $1,630) The Center for Medicare and Medicaid Services (CMS) every year announces annual adjustments to the amount in controversy threshold

Read More
07 Feb

Responding to Record Requests on a Timely Basis.

Health care providers are increasingly seeing request for records from all types of payors including but not limited Medicaid, Medicare and commercial insurance providers. The basis for receiving a requests for records could be as a result on any number of reasons, including compliance, aberrant billing practices or as a result of a ZPIC audit

Read More
04 Mar

Hospital enters $85 million settlement for alleged Stark Law violations

Halifax Hospital agreed Monday, March 3, 2014, to settle a whistleblower case for alleged Stark Law violations with the U.S. Justice Department in the amount of $85 million — an amount so large it is more than twice the previous recors for hospital systems accused of Medicare fraud.  The Daytona Beach, Florida  hospital is accused of

Read More
23 Aug

Gaitan Law Group Successfully Reduces a $736,305.93 Overpayment to $6,826.00

  CMS sought recovery of an alleged overpayment in excess of $730,000 from a diagnostic laboratory, upon the conclusion and recommendation of Safeguard Services (SGS) to deny all claims submitted for 3,006 Medicare beneficiaries.  Mr. Gaitan and Mr. Suarez, of our health care practice group, appealed the overpayment claim through the reconsideration (second level appeal),

Read More
09 Jan

Medicare delays RAC demonstration program intended to hold back payments to hospitals

CMS has announced that it will postpone its Recovery Audit (RAC) Prepayment Review demonstration project that would have held up payments to hospitals until the Medicare RAC reviews the claim to ensure that the provider complied with all Medicare payment rules. The Medicare RAC Prepayment Review demonstration called for the RACs to conduct prepayment review of claims for 15 procedures that historically result in high rates of improper payments. Many doctors were unhappy with the proposed program, especially cardiologists, who would be most affected since 11 of the 15 procedures identified for Medicare RAC prepayment review affect cardiologists.

Read More