ALJ Hearing Defense - Federal Lawyer
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ALJ Hearing Defense

Lawyers Representing Healthcare Providers in Medicare Administrative Law Judge (ALJ) Hearings

Lynette Byrd
Attorney Lynette Byrd
Medicare Administrative Law Judge Team Lead
Former DOJ Attorney envelope icon Contact Lynette
Nick Oberheiden
Attorney Nick Oberheiden
Medicare Administrative Law Judge Team Lead envelope icon Contact Nick
Wade McFaul
Wade McFaul
Medicare Administrative Law Judge Consultant
Former HHS-OIG Assistant Special Agent-in-Charge

As a healthcare provider that relies on Medicare reimbursements, not getting paid—or worse, facing recoupment liability—can have serious consequences for your practice or business. You expect Medicare to cover the services your team provides, and you rely on a steady stream of reimbursements to keep the lights on, pay your staff, and take care of your patients.

So, when a Medicare auditor steps in and says your practice or business shouldn’t be paid, this is a big deal.

Unfortunately, this scenario is all too common. Fee-for-service auditors working with the Centers for Medicare and Medicaid Services (CMS) routinely deny payment and seek recoupments from program-participating providers. While their efforts to prevent Medicare fraud are valid in some cases, many audits result in unjustified penalties. As a result, many providers find themselves in need of an ALJ hearing defense lawyer to start the appeal process.

Lawyers for Medicare ALJ Hearing Defense

Our lawyers represent healthcare providers and other businesses in the healthcare industry in Medicare audit appeals. While the appeals process generally starts with submitting a written request for redetermination to the Recovery Audit Contractor (RAC) or Medicare Administrative Contractor (MAC) that conducted the audit, providers and other businesses are often unable to achieve favorable results at this stage. In many cases, they try to handle their requests for redetermination on their own, and they find themselves stonewalled by a contractor that is solely focused on making sure it gets paid by CMS.

The same is true of the second stage of appeals—filing a reconsideration request with a Qualified Independent Contractor (QIC) is often met with a reconsideration decision letter that doesn’t go their way, and includes information for the third stage for further review if they don’t agree with the Medicare Appeals Council. But, at the third stage, providers and businesses have the ability to attend a hearing before an administrative law judge (ALJ) with the Office of Medicare Hearings and Appeals (OMHA). The OMHA is an independent entity, and its ALJs have a duty to consider all pertinent facts, all the evidence, witness testimony, and arguments in an oral hearing before rendering an unbiased written decision.

In some cases, Medicare-participating providers can also find themselves facing an ALJ hearing without submitting hearing requests. This can happen if an ALJ determines, “that you are a party who was found liable for the services or items at issue in a prior decision or may be found liable based on a review of the record,” in another administrative hearing. In this scenario, an effective ALJ hearing defense is critical for avoiding unnecessary consequences.

We provide ALJ hearing defense representation for Medicare-participating providers nationwide. If you need to request an ALJ hearing at the OMHA—or if you have already filed an appeal request with the hearing office (or received a notice) and are awaiting your hearing date—we encourage you to contact us promptly. When you do, you will speak with one of our senior-level ALJ hearing defense lawyers one-on-one. Your lawyer will explain the ALJ hearing process in detail, and then your lawyer will quickly begin the process of gathering the necessary billing records and preparing the arguments needed to demonstrate why the auditor’s or ALJ’s determination was flawed.

Grounds to File an ALJ Hearing Request with OMHA

When can (and should) you file an ALJ hearing request with OMHA? Medicare-participating healthcare providers and other businesses can dispute the outcomes of their MAC and RAC audits on numerous grounds. Flawed audit determinations are common, and you should not be forced to accept underpayment from Medicare. Some examples of common grounds for filing an ALJ hearing request with OMHA include:

  • Applying current Medicare billing regulations to past billings that were subject to a prior set of rules;
  • Applying outdated Medicare billing regulations to recent billings governed by an updated set of rules;
  • Improperly classifying services or items as ineligible for Medicare reimbursement;
  • Improperly classifying a provider’s Medicare billing as upcoding or unbundling; and,
  • Improperly calculating participating providers’ reimbursement entitlements.

Again, these are just examples. Errors during Medicare audits are extremely common, and they can take numerous different forms. If you have any reason to believe that your practice or business has been improperly punished by a Medicare auditor, we encourage you to contact us about filing to present an ALJ hearing defense as soon as possible. Under CMS’s regulations, you only have a limited amount of time to file, so it is important that you start the process promptly.

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)

Possible Outcomes After Asserting an ALJ Hearing Defense

A hearing before an ALJ at the OMHA can have a few different outcomes. When we provide representation for ALJ hearing defense, we thoroughly examine the relevant billings, billing regulations, and auditing practices so that we can target a specific favorable outcome based on the circumstances at hand. We then build a comprehensive case for why the auditor’s or prior ALJ’s determination should be overturned. After the hearing, the ALJ may rule that either:

  • The auditor’s determination or prior ALJ ruling was flawed and should be reversed;
  • The auditor’s determination was flawed in part, and redetermination of the provider’s or business’s is necessary to ensure a just result; or,
  • The auditor’s determination or prior ALJ ruling should be upheld.

While we have had significant success at OMHA hearings, we have also represented numerous clients at subsequent stages of the Medicare appeals process. If the ALJ incorrectly rules that your practice or business is liable for overbilling Medicare, we can continue to pursue a just outcome—including taking your Medicare audit determination to federal district court if necessary.

How Our Lawyers Can Assist with Medicare ALJ Hearing Defense

A hearing before an ALJ at the Office of Medicare Hearings and Appeals is a formal legal process that can have significant financial consequences for your practice or business. As a result, an effective ALJ hearing defense is paramount. Here is what we can do to help:

1. Identifying All Flaws in the RAC or MAC’s Audit Determination

Our lawyers and Medicare compliance consultants have extensive experience identifying flaws in RAC and MAC audit determinations. With comprehensive knowledge of the current and prior Medicare billing regulations, we can identify all flaws that warrant a reversal on appeal.

2. Accurately Calculating Your Practice or Business’s Medicare Reimbursement Rights

Once we identify the flaws in your practice or business’s RAC or MAC audit, we will accurately calculate its Medicare reimbursement rights. If we can show not only what the auditors did wrong, but also how much your practice or business is entitled to receive from Medicare, this can often help to facilitate a favorable result.

3. Building a Comprehensive Case to Present to the ALJ

We will rely on our experience and insights to build a comprehensive case to present to the ALJ. Applying the pertinent Medicare regulations to your practice or business’s billings, we will work to convince the ALJ that the only just outcome is an outcome in your favor.

FAQs: Presenting an Effective Medicare ALJ Hearing Defense

When Can Healthcare Providers Request an ALJ Hearing?

Healthcare providers can request ALJ hearings at the Office of Medicare Hearings and Appeals when they receive unfavorable—and unjustified—audit determinations from CMS’s audit contractors. However, they must go through the process of submitting a request for redetermination with their RAC or MAC and a request for reconsideration with a QIC first. When necessary, providers can request ALJ hearings to dispute auditors’ determinations of their Medicare Part A&B, Part C, and/or Part D billings.

How Long Do Healthcare Providers Have to Request an ALJ Hearing?

Generally, healthcare providers have 60 days from receipt of a QIC’s reconsideration decision to file a request for an ALJ hearing. However, if a QIC fails to render a reconsideration decision by its deadline, then the provider can request a hearing without a decision being rendered.

How Can I Defend My Practice’s Medicare Billings During an ALJ Hearing?

Defending a participating provider’s Medicare billings during an ALJ hearing requires a clear understanding of both: (i) the relevant Medicare billing rules and regulations; and, (ii) the errors made during the audit process. An understanding of the OMHA ALJ hearing process is critical as well. At Oberheiden P.C., our lawyers and consultants have extensive experience assisting providers with Medicare billing compliance as well as defending providers during audits and ALJ hearings. We can identify all grounds to challenge the outcome of your practice’s audit, and we can present these grounds to the ALJ on your behalf.

Can (and Should) I Hire a Lawyer for an ALJ Hearing?

Due to the financial and legal implications involved, it is in healthcare providers’ best interests to engage experienced counsel to represent them during an ALJ hearing. Our lawyers represent providers in ALJ hearings nationwide, and you can get started with a free and confidential consultation.

What if I Disagree with the Outcome of My ALJ Hearing at the OMHA?

If you disagree with the outcome of your ALJ hearing at the OMHA, you have the right to continue to the next stage of the Medicare audit appeals process. An ALJ hearing is the third of five stages, with the final stage being a legal challenge in federal district court.


Discuss Your ALJ Hearing Defense with a Lawyer at Oberheiden P.C.

Do you have more questions about ALJ hearing defense? If so, we invite you to get in touch. Please call 888-680-1745 or contact us online to arrange a free and confidential consultation with a lawyer at Oberheiden P.C.

Why Clients Trust Oberheiden P.C.

  • 2,000+ Cases Won
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  • Experienced Trial Attorneys
  • Former Department of Justice Trial Attorney
  • Former Federal Prosecutors, U.S. Attorney’s Office
  • Former Agents from FBI, OIG, DEA
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