This article will feature one part poll, one part legal discussion.
First, the poll: do you have the sense that administrative law judge (ALJ) hearings are getting harder to win?
Last month I participated in a hearing in a case with a million-dollar overpayment. The hearing seemed to go really well. At the end, both my client and I were confident that the judge had really listened to our arguments.
So, imagine our surprise when the second business day after the hearing, at 8 a.m., we received a lengthy faxed decision ruling against us. It was hard to believe such a lengthy decision could have been turned around so fast.
Just a few days later, a client in the southeast called me and asked if I could talk to their appeals team. They indicated that the team is becoming depressed because they are losing so many ALJ appeals. They wanted to know if this experience reflected on them or was part of a wider trend.
A few days after that, a client in the southwestern U.S. called with a virtually identical query. So here’s my question to you: does it feel like ALJs are more likely to rule for the contractors? Please feel free to email me your thoughts.
The second topic involves situations in which there is an internal disagreement about whether to make a refund or to change make a change in policy prospectively. When two people disagree about how to interpret a provision, each of them should lay out all of the evidence they have supporting their position.
I’ve talked about the regulatory hierarchy, and I think it’s useful to consider this from the top down. What does the Constitution say? Are there any statutes or laws that are relevant? What federal or state regulations exist? Is there a national coverage determination (NCD)? I think it’s helpful to consider them in precisely that order, because sort of like paper covers rock and rock smashes scissors, statutes cover a regulation, and the Constitution smashes both.
When one of the participants has a statute, regulation, or NCD that answers the question, they beat anyone pointing to a local coverage determination (LCD), Medicare manual, Medicare contractor bulletin, or anything else, because LCDs, manuals, and bulletins are merely guidance, and not binding.
It is somewhat common to encounter situations where the only evidence people will cite will be from manuals or contractor FAQs. I wanted to re-emphasize that I can’t think of a situation in which a refund is required simply because of language in a manual or a carrier issuance. In the absence of a statute or regulation, you might change your policy going forward, but I would discourage you from cutting a refund check if the services were provided and were medically necessary.
The bottom line is that if someone believes that you are breaking a rule, it is both reasonable and wise to ask them to, in the words of Aretha Franklin, prove it, prove it, prove it.
Prove it to me. If you do it with r-e-s-p-e-c-t, they should feel appreciative of the opportunity to present their arguments.
Listen to healthcare attorney David Glaser every Monday morning for his “Risky Business” segment on Monitor Mondays with Chuck Buck, 10 Eastern.
EDITOR’S NOTE:
The opinions expressed in this article are solely those of the author and do not necessarily represent the views or opinions of MedLearn Media. We provide a platform for diverse perspectives, but the content and opinions expressed herein are the author’s own. MedLearn Media does not endorse or guarantee the accuracy of the information presented. Readers are encouraged to critically evaluate the content and conduct their own research. Any actions taken based on this article are at the reader’s own discretion.
Literature is ripe with classic phrases that seem timelessly apropos. For example, take the partial federal government shutdown. For days, the phrase repeated in the
The Medicare Advantage (MA) program has grown significantly over the past two decades, becoming a popular alternative to traditional Medicare fee-for-service (FFS). As of 2023,
Please log in to your account to comment on this article.
Join Beth Wolf, MD, CPC, CCDS, for an in-depth webcast on the FY2025 spinal fusion MS-DRG updates. Discover key changes in DRG classification, understand impacts on documentation and CMI, and learn strategies to ensure compliance.
Join Angela Comfort, DBA, MBA, RHIA, CDIP, CCS, CCS-P, as she presents effective strategies to strengthen collaboration between CDI, coding, and quality departments in acute care hospitals. Angela will also share guidance on implementing cross-departmental meetings, using shared KPIs, and engaging leadership to foster a culture of collaboration. Attendees will gain actionable tools to optimize documentation accuracy, elevate quality metrics, and drive a unified approach to healthcare goals, ultimately enhancing both patient outcomes and organizational performance.
Optimize your outpatient clinical documentation and gain comprehensive knowledge from foundational practices to advanced technologies, ensuring improved patient care and organizational and financial success. This webcast bundle provides a holistic approach to outpatient CDI, empowering you to implement best practices from the ground up and leverage advanced strategies for superior results. You will gain actionable insights to improve documentation quality, patient care, compliance, and financial outcomes.
Enhancing outpatient clinical documentation is crucial for maintaining accuracy, compliance, and proper reimbursement in today’s complex healthcare environment. This webcast, presented by industry expert Angela Comfort, DBA, RHIA, CDIP, CCS, CCS-P, will provide you with actionable strategies to tackle complex challenges in outpatient documentation. You’ll learn how to craft detailed clinical narratives, utilize advanced EHR features, and implement accurate risk adjustment and HCC coding. The session also covers essential regulatory updates to keep your documentation practices compliant. Join us to gain the tools you need to improve documentation quality, support better patient care, and ensure financial integrity.
Dr. Ronald Hirsch provides critical details on the new Medicare Appeal Process for Status Changes for patients whose status changes during their hospital stay. He also delves into other scenarios of hospital patients receiving custodial care or medically unnecessary services where patient notifications may be needed along with the processes necessary to ensure compliance with state and federal guidance.
Healthcare organizations face complex regulatory requirements under the No Surprises Act and Price Transparency rules. These policies mandate extensive fee disclosures across settings, and confusion is widespread—many hospitals remain unaware they must post every contracted rate. Non-compliance could lead to costly penalties, financial loss, and legal risks. Join David M. Glaser Esq. as he shows you how to navigate these regulations effectively.
Protect your facility from unwanted audits! Join Becky Jacobsen, BSN, RN, MBS, CCS-P, CPC, CPEDC, CBCS, CEMC, and take a deep dive into both the CMS and AMA guidelines for reporting post operative pain blocks. You’ll learn how to determine if the nerve block is separately codable with real life examples for better understanding. Becky will also cover how to evaluate whether documentation supports medical necessity, offer recommendations for stronger documentation practices, and provide guidance on educating providers about documentation requirements. She’ll include a discussion of appropriate modifier and diagnosis coding assignment so that you can be confident that your billing of post operative pain blocks is fully supported and compliant.
During this RACmonitor webcast Dr. Ronald Hirsch spotlights the areas of the OIG’s Work Plan and the findings of their most recent audits that impact utilization review, case management, and audit staff. He also provides his common-sense interpretation of the prevailing regulations related to those target issues. You’ll walk away better equipped with strategies to put in place immediately to reduce your risk of paybacks, increased scrutiny, and criminal penalties.
Copyright © 2024 RACmonitor. Powered by MedLearn Media.
Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24
