Hospice Successful Overpayment Appeal

Successful appeal of one of the firm’s hospice client’s overpayment resulted in the award of Administrative Law Judge (ALJ) interest (approximately $1.7 million) paid to the client. As posted in our July 27, 2022 post, Mr. Rafael (Ralph) Gaitan led his client in overturning the UPIC’s extrapolated overpayments which required the Centers for Medicare & Medicare Services (CMS), Medicare Administrative Contractor (MAC),  to refund approximately five million dollars of claims paid to the hospice and recouped by the MAC post-audit.

Presentment of Evidence

At the ALJ hearing, Mr. Gaitan presented oral and legal arguments supported by testimonial and medical documentation evidence to overcome various denial reasons for which the hospice’s health care claims were denied during the post payment audit conducted by the UPIC contracted by CMS. Mr. Gaitan was also able to prepare his client’s Spanish speaking witnesses in a manner that was efficient, coherent and effective to demonstrate medical necessity in the claims previously submitted by the hospice for reimbursement. In total including refund of recouped payments and ALJ interest, the firm’s client collected slightly over $6.7 million via the hospice’s successful overpayment appeal.

Collaboration is Key to Success

Although every case and every client provider is different, the strategies developed by Mr. Gaitan have been been useful to the firm’s clients in challenging overpayments as well as navigating through the financial pressures imposed by CMS’ recoupment and collection efforts. It is important to note that not all appeals result in ALJ interest or have similar results; however, Mr. Gaitan has had proven track record which has benefited his clients. Collaboration between the attorney and client is necessary and key as in this case, resulting in the hospice successful appeal of overpayment.

Experience and Knowledge of Medicare Rules and Regulations

Mr. Gaitan is able to assist all different types Medicare enrolled health care providers at any level of appeal and has flexible payment arrangements including contingency fees for payment of legal fees. If your facility is faced with an audit or overpayment determination please feel free to contact Ralph Gaitan who can provide a free initial consultation as well as a road map for the facility to take to prevent potential recoupment of payments, to prepare medical records for submission as evidence, and if necessary submission of an extended repayment plan prior to, during and after each of the CMS appeal levels including the redetermination, reconsideration and ALJ hearings.

Through his many years practicing administrative law either before Florida administrative agencies or CMS contractors, Mr. Gaitan has developed the necessary experience and knowledge required to navigate his clients with the many Medicare & Medicaid rules and regulations. Accordingly, we invite you to contact Mr. Gaitan to discuss your particular case, he can be reached via email at [email protected] or at (786) 440-8115. We look forward to the opportunity to assist, guide and counsel your facility’s health care compliance and legal needs with the Medicare or Medicaid program.

Successful Hospice Appeal of Overpayment, required CMS form included here.
Hospice Successful Appeal of Overpayment required submission of the OMHA-100.