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CMS Appeals

We Represent Healthcare Providers In All Types of CMS Appeals (Medicare Parts A, B, C, and D)

Lynette Byrd
Attorney Lynette Byrd
CMS Appeals Team Lead
Former DOJ Attorney envelope iconContact Lynette directly
Kevin M. Sheridan
Kevin M. Sheridan
Medicare Audit & Appeals Consultant
Former FBI Special Agent
Wade McFaul
Wade McFaul
Medicare Audit & Appeals Consultant
Former HHS-OIG Assistant Special Agent-in-Charge

As a healthcare provider or business that relies heavily on Medicare reimbursements to manage your expenses and make payroll, denial of reimbursement requests can have a major impact on your practice or company. While some denials result from billing errors and oversights, many are unwarranted. As a result, many healthcare providers and businesses find themselves needing to file CMS appeals.

We represent healthcare clients in CMS appeals nationwide. We handle appeals under Medicare Parts A, B, C, and D at all levels of the process. If your practice or company is facing recoupments, prepayment review, or other billing-related penalties unnecessarily, our lawyers can guide you through the appeals process while dealing with CMS, its auditors, and all pertinent administrative and judicial bodies on your practice’s or company’s behalf.

What Healthcare Providers and Companies Should Know About CMS Appeals

If you have never been through a CMS appeal, there is a lot you need to know. The CMS appeals process is inordinately complex, and the grounds for pursuing an appeal and the steps involved in reversing coverage determination are determined by an extensive body of federal laws and regulations. With this in mind, here are five important facts healthcare providers and companies should know about appealing the outcome of a CMS audit:

1. Medicare Parts A, B, C, and D All Have Different Appeals Processes

Medicare Parts A, B, C, and D all have different appeals processes. While CMS appeals involving Medicare Parts A and B are similar in certain respects, there are some key differences as well. Medicare Advantage (Part C) appeals are subject to processes of their own, and the same is true of Medicare Part D.

As a result, simply knowing where to begin can be challenging for many healthcare practitioners, business owners, and executives. With our experience handling all types of Medicare appeals, we can help you understand the process and guide you forward step-by-step. Our lawyers can explain what you should expect along the way, and we can provide representation focused on achieving a favorable result as efficiently as possible.

2. There Are Several Stages of CMS Appeals

With all types of Medicare coverage, there are several stages of CMS appeals. While we have had success reversing unfavorable audit determinations at the initial stages of the process, many providers and companies will need to go through multiple stages to secure the outcomes they deserve. Ultimately, what is necessary varies case-by-case, and the outcome at each stage is fundamentally beyond healthcare providers’ and companies’ control. As an example, the stages of CMS appeals for Medicare Parts A and B include:

  • Medicare Administrative Contractor (MAC) Redetermination
  • Qualified Independent Contractor (QIC) Reconsideration
  • Office of Medicare Hearings and Appeals (OMHA) Decision
  • Medicare Appeals Council Review
  • U.S. District Court Judicial Review

Since the first stage involves dealing with the MAC that conducted the audit, finding success at this stage can prove particularly challenging. With that said, we’ve had success here, and our strategic, evidence-based approach to CMS appeals has proven effective at all stages of the process.

3. Providers and Companies Need to Make Informed Decisions About Pursuing CMS Appeals

Given the challenges involved, healthcare providers and companies need to make informed decisions about pursuing CMS appeals. If the auditor’s findings are legitimate, then pursuing an appeal likely won’t be worthwhile—and the provider’s or company’s resources may be better spent enhancing its billing compliance policies and procedures. However, if the auditor’s findings aren’t legitimate, then having the findings reversed on appeal could be critical for avoiding unnecessary consequences. This includes not only unnecessary recoupment liability and other billing-related penalties, but also enhanced scrutiny from CMS and its audit contractors going forward.

4. Experienced Legal Representation is Critical

To navigate the CMS appeals process as quickly and successfully as possible, healthcare providers and companies need experienced legal representation. At Oberheiden P.C., we have extensive experience handling appeals on behalf of all types of providers and companies nationwide. If you believe you may need to file a CMS appeal, we encourage you to contact us promptly for advice regarding your next steps.

5. CMS Appeals Are Warranted in Many Circumstances

While an appeal isn’t always warranted, CMS appeals are warranted in many circumstances. Auditors routinely make mistakes, and these mistakes can unduly expose healthcare providers and companies to significant adverse financial consequences. Our lawyers can review your organization’s audit results to determine if an appeal is justified; and, if so, we can get to work promptly to ensure that you do not run out of time to assert your organization’s appellate rights.

How Our Lawyers Help with CMS Appeals (Medicare Parts A, B, C, and D)

What can you expect when you engage Oberheiden P.C. for your healthcare practice’s or business’s CMS appeal? As your organization’s CMS appeals counsel, we will:

  • Evaluate All Possible Grounds for Filing an Appeal – Once you engage our firm, we will work quickly to evaluate all possible grounds for filing an appeal. Our lawyers and consultants are intimately familiar with the CMS billing rules and regulations, and we can rely on our experience to quickly advise you of the options you have available.
  • Clearly Document the Flaws in the Appeal Process or Outcome – We will also rely on our experience to clearly document the flaws in the appeal process or outcome (or both). As discussed above, mistakes are common, and CMS’s auditors routinely seek unjustified recoupments and other penalties.
  • File Your Appeal Promptly – CMS appeals are subject to strict deadlines. We will work to file your appeal as efficiently as possible; and, if necessary, we can initiate the process promptly to preserve your organization’s ability to achieve a just result.
  • Pursue Your Appeal Through All Necessary Stages – Our goal in every case is to successfully appeal our clients’ unfavorable audit determinations at the earliest possible stage. With that said, we are prepared to do what it takes to protect our clients, and we will shepherd your organization’s appeal through as many stages as are necessary.  
  • Seek Relief in Federal Court if Necessary – If necessary, we can also seek relief on your organization’s behalf in federal court. Going to court is the last stage in the CMS appeals process; and, while this can be time-consuming, it can also be essential for avoiding unwarranted immediate and long-term consequences.

Put our highly experienced team on your side

Dr. Nick Oberheiden
Dr. Nick Oberheiden

Founder

Attorney-at-Law

Lynette S. Byrd
Lynette S. Byrd

Former DOJ Trial Attorney

Partner

Brian J. Kuester
Brian J. Kuester

Former U.S. Attorney

Amanda Marshall
Amanda Marshall

Former U.S. Attorney

Local Counsel

Joe Brown
Joe Brown

Former U.S. Attorney

Local Counsel

John W. Sellers
John W. Sellers

Former Senior DOJ Trial Attorney

Linda Julin McNamara
Linda Julin McNamara

Federal Appeals Attorney

Aaron L. Wiley
Aaron L. Wiley

Former DOJ attorney

Local Counsel

Roger Bach
Roger Bach

Former Special Agent (DOJ)

Chris Quick
Chris J. Quick

Former Special Agent (FBI & IRS-CI)

Michael S. Koslow
Michael S. Koslow

Former Supervisory Special Agent (DOD-OIG)

Ray Yuen
Ray Yuen

Former Supervisory Special Agent (FBI)

What Can You Expect from the Medicare Appeals Process?

CMS appeals can have a few different outcomes. At each stage of the process, the decision-maker can either (i) affirm the auditor’s determination, (ii) modify the auditor’s determination, or (iii) determine that the audit determination is flawed and no penalties are warranted. Once we assess the circumstances of your practice’s or organization’s audit, we can advise you regarding potential outcomes, and then we can execute a custom-tailored strategy focused on achieving a favorable result.

FAQs: Filing a CMS Appeal

How Can I Decide Whether to File a CMS Appeal?

Deciding whether to file a CMS appeal requires a clear understanding of CMS’s fee-for-service audit procedures as well as the accuracy of the outcome of your organization’s audit. Our lawyers and consultants have extensive experience overseeing and challenging all types of Medicare audits, and we can use our experience to help you make an informed decision about whether to file a CMS appeal.

How Do I Prove that My Practice’s or Organization’s Medicare Audit was Flawed?

Proving flaws in a Medicare audit requires a comprehensive understanding of all pertinent federal laws and regulations. The Medicare billing rules are exceedingly complex, and they change regularly. At Oberheiden P.C., we stay up-to-date on the latest Medicare billing requirements, and we can determine whether auditors applied the wrong standards or incorrectly calculating your practice’s or organization’s recoupment liability.

What is the Timeframe for a CMS Appeal?

The timeframe for CMS appeals varies depending on the type of appeal you need to file (i.e., Medicare Part A, B, C, or D) and the stage of the appellate process at which you are currently. While MACs must generally make their redetermination decisions within 60 days, other stages of the process can take significantly longer.

What Are the Chances of Winning a Medicare Appeal?

The chances of winning a Medicare appeal depend on two key factors: (i) the issues underlying your organization’s appeal (i.e., application of improper standards during the audit process); and, (ii) whether your organization engages experienced legal counsel. We have extensive experience representing providers and other organizations at all stages of the appeals process, and we have consistently been able to achieve favorable results for our clients.

How Do I Choose a Lawyer for the CMS Appeals Process?

When choosing a lawyer for the CMS appeals process, relevant experience is critical. The CMS appeals process is complex, and winning is not easy. But, it is possible—and, with the right approach, providers and companies can efficiently achieve favorable results with experienced counsel on their side.


Contact the CMS Appeals Lawyers at Oberheiden P.C.

If you need to know more about the CMS appeals process—or if you need counsel to file a CMS appeal—we encourage you to contact us promptly. To speak with an experienced CMS appeals lawyer at Oberheiden P.C. in confidence, please call 888-680-1745 or request an appointment online today.

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