Medicare Audits: Time is of the Essence

Miss an appeal deadline by one single day, and you lose your right to appeal an overpayment.

Today, I will be discussing the importance of timing. Timing is everything. Missing a deadline germane to any type of Medicare or Medicaid audit can be deadly. Miss an appeal deadline by one single day, and you lose your right to appeal an overpayment.

 If any of you has watched the popular sitcom Schitt’s Creek, then you know that when Johnny and Moira Rose (played by Eugene Levy and Catherine O’Hara, respectively) missed their deadline to file for and pay taxes, they lost their mansion, their money, and way of life. The same catastrophic loss can occur if a provider misses an appeal deadline.

Importantly, when it comes to Medicare appeals, your appeal is due 60 days after the reconsideration review decision, pursuant to 42 CFR § 405.1014: Request for an ALJ hearing or a review of a QIC dismissal. A third-level Medicare provider appeal is considered “filed” upon receipt of the complete appeal at the Office of Medicare Hearings and Appeals (OMHA), instead of the normal standard acceptance that an appeal is filed upon the mailing stamped date. As in, once you mail your appeal, it will be retroactively filed per the date of mailing. Not true for the third-level Medicare provider appeal. It is considered filed on the date of receipt.

Also, the regulatory clock starts ticking five days after the date the of the reconsideration review decision, because the thought is that the U.S. Postal Service will not take more than five days to deliver correspondence. Well, that assumption nowadays can be inaccurate. The Postal Service is a mess. Mail is sometimes received weeks after it was sent, which makes the date of delivery imperative.

We actually had a case in which the administrative law judge (ALJ) dismissed our appeal because the Postal Service delivered the mailing on the 61st day after the reconsideration review decision, including the five-day window. Literally, the 61st day. The reason that the appeal was received on the 61st day is that the 60th day fell on a holiday, a weekend, or a closure due to COVID – I cannot recall – but OMHA was closed at the time. The mail delivery person had to return the next day to deliver the appeal. Yet our appeal was dismissed based on this issue! We filed a motion to reconsider, but the ALJ denied it. Our only chance at presenting to the ALJ was squashed.

We appealed the ALJ’s denial to the Medicare Appeals Council, with hope of reasonableness. We have no decision yet.

Programming Note: Listen to healthcare attorney Knicole Emanuel’s RAC Report every Monday or Monitor Mondays, 10 Eastern.

Facebook
Twitter
LinkedIn
Email
Print

Knicole C. Emanuel Esq.

For more than 20 years, Knicole has maintained a health care litigation practice, concentrating on Medicare and Medicaid litigation, health care regulatory compliance, administrative law and regulatory law. Knicole has tried over 2,000 administrative cases in over 30 states and has appeared before multiple states’ medical boards. She has successfully obtained federal injunctions in numerous states, which allowed health care providers to remain in business despite the state or federal laws allegations of health care fraud, abhorrent billings, and data mining. Across the country, Knicole frequently lectures on health care law, the impact of the Affordable Care Act and regulatory compliance for providers, including physicians, home health and hospice, dentists, chiropractors, hospitals and durable medical equipment providers. Knicole is partner at Nelson Mullins and a member of the RACmonitor editorial board and a popular panelist on Monitor Monday.

Related Stories

What Everyone Knows About You

What Everyone Knows About You

It’s all in the data: and it’s available. A few years ago, I was giving a presentation to a group of cardiologists. I provided to

Read More

New Workflow Manages DRG Mismatches

Workflow increases productivity, while proving itself to be successful in reconciling DRG mismatches. When asking many clinical documentation improvement specialists (CDISs) what they dislike most

Read More

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

Mastering Good Faith Estimates Under the No Surprises Act: Compliance and Best Practices

Mastering Good Faith Estimates Under the No Surprises Act: Compliance and Best Practices

The No Surprises Act (NSA) presents a challenge for hospitals and providers who must provide Good Faith Estimates (GFEs) for all schedulable services for self-pay and uninsured patients. Compliance is necessary, but few hospitals have been able to fully comply with the requirements despite being a year into the NSA. This webcast provides an overview of the NSA/GFE policy, its impact, and a step-by-step process to adhere to the requirements and avoid non-compliance penalties.

Mastering E&M Guidelines: Empowering Providers for Accurate Service Documentation and Scenario Understanding in 2023

Mastering E&M Guidelines: Empowering Providers for Accurate Service Documentation and Scenario Understanding in 2023

This expert-guided webcast will showcase tips for providers to ensure appropriate capture of the work performed for a visit. Comprehensive examples will be given that demonstrate documentation gaps and how to educate providers on the documentation necessary to appropriately assign a level of service. You will gain clarification on answers regarding emergency department and urgent care coding circumstances as well as a review of how/when it is appropriate to code for E&M in radiology and more.

June 21, 2023
Breaking Down the Proposed IPPS Rule for FY 2024: Top Impacts You Need to Know

Breaking Down the Proposed IPPS Rule for FY 2024: Top Impacts You Need to Know

Set yourself up for financial and compliance success with expert guidance that breaks down the impactful changes including MS-DRG methodology, surgical hierarchy updates, and many new technology add-on payments (NTAPs). Identify areas of potential challenge ahead of time and master solutions for all 2024 Proposed IPPS changes.

May 24, 2023

Trending News