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How to Manage Medical Billing Disputes

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Tips for Avoiding Them as a Provider (And Handling Them When They Arise)

If you treat even a handful of Medicare / Medicaid patients at your medical practice, the amount of paperwork you process back and forth with the government (and their contractors) over the course of a year can really add up. It’s easy to make mistakes.

Any provider might eventually enter into a medical billing dispute with CMS or other government offices, and the longer you’re in practice, the more likely it is to happen.

Still, even if the disputes emerge from a mistake made in good faith, it’s important that you approach them carefully.

Billing disputes can have huge consequences. You could be denied payment, for example. CMS might impose pre-payment review on all your future invoices. Or they might allege that you owe the government back pay for erroneous invoices in the past. It isn’t uncommon for Medicare to demand tens of thousands of dollars from a single provider during a medical billing dispute — sometimes millions.

In fact, there are Strike Force offices set up across the country whose sole purpose is to find evidence of health care fraud. Those investigations often begin with routine ZPIC audits or medical billing disputes – but they can end in criminal prosecution, where the penalties range from the loss of your medical license to imprisonment.

The best way to manage a Medicare billing dispute is to hire an experienced federal health care defense lawyer. Below, we offer a few helpful guidelines for navigating disputes in the future, and we explain how the right law firm can help.

Remember: Simple Errors Are Responsible for Many Medical Billing Disputes

Examples of easy but common errors to avoid include:

  • Entering the wrong codes when invoicing for services covered by Medicaid / Medicare
  • Accidentally billing for the wrong patient
  • Engaging in anything that could ever be perceived as a kickback (even if it seems like an honest, reasonable business tactic in your mind)
  • Billing for services that CMS and its contractors might dispute as “medically unnecessary”

Know That Medicare Contractors Are Biased & Don’t Have Final Authority

Medical billing disputes usually begin when a MAC, RAC, or ZPIC spots a red flag or irregularity in your invoicing patterns.

Sometimes, these red flags come up even when there isn’t an identifiable error in any individual invoice. For example, if your practice treats an unusually high number of Medicare patients, you could attract federal attention — even if you aren’t doing anything wrong.

Unfortunately, once these private government contractors pull out their magnifying glasses, they’re likely to find something to dispute. That is, after all, how they make their money.

CMS contractors, such as MACs, have contingency agreements with the government, meaning they get to keep a portion of the funds they successfully recover on Medicare’s behalf. Naturally, they won’t succeed in every case — so it is in their best business interest to pursue as many “leads” as possible.

That isn’t fair to medical practices already overburdened in the current regulatory landscape. But it is reality.

Fortunately, even if these contractors do render a self-serving determination against your practice, you still have rights and options. That brings us to the Medicare appeals process.

Familiarize Yourself with the Medicare Appeals Process

If you’ve already received an unfavorable determination from a MAC, RAC, or ZPIC, don’t despair. A multi-stage appeals process is available to give you one chance of success after another.

While the process is time-intensive, requires strategic planning, and can feel overwhelming, you should take heart in knowing that many health care providers have successfully overcome costly initial determinations on appeal.

Your chances of success are much greater if you hire a federal health care defense lawyer. They can prepare your appeals, fight for your interests, and avoid exposing your business to liability or making other damaging mistakes.

The five stages of appeal after a medical billing dispute with CMS are as follows:

  1. Redetermination by MAC staff members
  2. Reconsideration by a Qualified Independent Contractor (QIC)
  3. Administrative Law Judge (ALJ) Hearing / Office of Medicare Hearings and Appeals (OMHA) review
  4. Medicare Appeals Council review (sometimes referred to simply as “Council review”)
  5. Judicial review in a U.S. District Court

Every stage has its own procedures, qualifying guidelines, and filing timelines. You must pay close attention to each.

Be Mindful of Criminal Fraud Implications

As we mentioned earlier, civil billing disputes always have criminal law concerns in their echoes. CMS contractors are known to refer cases to federal law enforcement for criminal investigation and vice versa. Statutes to be aware of include:

  • Health care fraud: You’ll find the most commonly used statute is 18 U.S. Code § 1347, which makes it a crime to intentionally defraud government programs like CMS. Intent is key. Prosecutors must be able to prove you acted knowingly and willfully — a very high burden, indeed.
  • Attempt / conspiracy to commit health care fraud: Contributing to a scheme to defraud Medicare, or attempting to do so, can be enough to support a criminal charge under 18 U.S. Code § 1349. Federal law enforcement will use this statute to go after people whose conduct isn’t culpable enough to constitute a crime under § 1347 above.
  • Mail fraud: 18 U.S. Code § 1341 makes it a crime to deposit any materials or matter in “any post office or authorized depository for mail” or to use “any private or commercial interstate carrier” in furtherance of committing fraud.
  • Wire fraud: Similar to § 1341 above, 18 U.S. Code § 1343 makes it a federal crime to transmit (or cause to be transmitted) “any writings, signs, signals, pictures, or sounds” by means of “wire, radio, or television communication in interstate or foreign commerce.” Similar state provisions exist as well.

Talk to the Medicare Appeals Law Attorneys at Oberheiden, P.C.

Whether you are already in a medical billing dispute or you simply want sound advice for avoiding one in the future, we urge all medical providers in the United States to retain legal counsel for ongoing guidance. Specifically, you should choose a law firm with extensive experience in the sophisticated field of federal health care law, federal criminal defense, and regulatory compliance.

The former federal prosecutors at Oberheiden, P.C. have a significant record in leading health care providers to success in the face of medical billing disputes, criminal suspicion, and unwarranted government interference.

We offer free and confidential consultations. To speak with one of our federal health care defense attorneys, please contact us online or call (888) 727-0472 right away.

Federal Medicare Disputes Law Firm. Primary Office in Dallas, TX.

This information has been prepared for informational purposes only and does not constitute legal advice. This information may constitute attorney advertising in some jurisdictions. Merely reading this information does not create an attorney-client relationship. Prior results do not guarantee similar outcomes for any client or potential client in the future. Oberheiden, P.C. is a Texas professional corporation with its headquarters in Dallas. Mr. Oberheiden limits his practice to federal law.
Orange County 714-294-2000
Los Angeles 310-873-8140
Detroit 313-888-8807
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