Medicare & Medicaid Overpayment Appeals

• Fiscal Intermediaries (FI)
• Regional Home Health Intermediaries (RHHI)
• Carriers
• Medicare Administrative Contractors (A/B/MAC)
• Durable Medical Equipment Medicare Administrative Contractors (DME MAC)
• Zone Program Integrity Contractor (ZPIC)
• Recovery Audit Contractors (RAC

Recent successes include:

• Rafael A. Gaitan appealed a Medicare overpayment claim against a laboratory, successfully reducing the claim to less than 1% — from $736,305.82 to $6,826.00.
• Rafael A. Gaitan appealed a Medicaid overpayment claim against a Home Health Care Provider, successfully reducing the claim, plus sanctions and costs to less than .01% — from $204,558.68 to $148.93.

Affordable Rates

We offer flexible fee arrangements, depending on the client’s situation.  Legal services are provided under hourly, flat-fee, and contingency agreements.  Flat-fee agreements start as low as $5,000.

At Gaitan Law Group, our health care team integrates the experience of respected litigators with the specialized knowledge of health care professionals, the know-how of a former medical clinic administrator and the insight of a former attorney of HHS at the ALJ Office (OMHA).

Whether a Medicare overpayment is initiated by the RAC, the carrier, the DME MAC or other entity, the same appeal process will be the same.  Over the years, the health care attorneys at Gaitan Law Group have successfully appealed overpayment determinations throughout each of the following levels:

First Level of Appeals – Redetermination

Once the claim denial has been reviewed by the Medicare carrier, intermediary or MAC it may be appealed in writing by requesting a redetermination of the claim.  Redetermination decisions will be provided to the Medicare provider in writing and must provide an explanation for the determination. When the claim denial is upheld, the provider may appeal the decision through a reconsideration.

Second Level of Appeals – Reconsideration

When a Medicare provider or supplier is dissatisfied with the outcome of the redetermination, a written Request for Reconsideration may be filed to the qualified independent contractors (QICs).  The QIC reconsideration is usually the best time to involve legal counsel, as this will generally be the last time during the administrative process that the appealing provider or supplier can submit new documentation to challenge the overpayment determination.  Before submitting a Request for Reconsider, a Medicare provider or supplier should align itself with a qualified health care attorney in order to ensure that the administrative record is complete and that its appeal rights are preserved.

Third Level of Appeals – Office of Medicare Hearings and Appeals (OMHA) Administrative Law Judge (ALJ) Hearings

If a provider or supplier is dissatisfied with the result of the reconsideration, a hearing before an ALJ may be requested. Requests for an ALJ hearing must be filed in writing with the entity specified in the QIC’s reconsideration notice and must be timely received.  At the OMHA ALJ hearing, the appellant and CMS will have the opportunity to offer testimony, conduct discovery, subpoena witnesses, and can proceed in a manner similar to that of a civil trial.  At this level, Medicare providers and suppliers should be represented by health care attorney with specific experience handling Medicare ALJ hearings.

Fourth Level of Appeals – Medicare Appeals Council (MAC)

If the ALJ decision is unfavorable, a Medicare provider or supplier may file a request for review with the Medicare Appeals Council. The MAC appeal is in writing and is limited to the same issues and evidence considered by the ALJ.  The Appeals Council may either modify or reverse the ALJ’s decision or may remand (send back) the case to the ALJ for another hearing.

Fifth Level of Appeals – Federal District Court

When the decision of the Appeals Council is unfavorable to the Medicare provider or supplier, a law suit may be filed in federal district court.  Only an attorney admitted to the federal bar can present a case to the federal district court.  This is the last level of appeals available to providers and suppliers.