Overview

With more than 60 million beneficiaries, the Centers for Medicare & Medicaid Services (CMS) processes more than 1 billion Medicare Part A and Part B Fee-for-Service (FFS) claims each year. The vast majority of these claims are processed without undergoing claims review, creating vulnerability for the Medicare Trust Funds. Authorized by various legislative actions, CMS has contracted with claims review entities to perform post-payment and pre-payment claims review. Health care providers and suppliers that have received a Medicare FFS claim denial or overpayment determination may appeal the initial determination through a five-stage uniform Part A and Part B appeals process. This book provides an overview of the Medicare FFS audit and Medicare appeals environment. It starts with an overview of the various CMS contractors performing claims review (including post-payment and pre-payment auditing activities). Then the Medicare Part A and Part B appeals process is examined. Finally, appeal strategies are set forth along with legal challenges applicable to Part A and Part B unfavorable claims determinations, with which attorneys should familiarize themselves when representing a health care entity subject to audit. A list of resources and references is included at the conclusion of this book.

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9781641059077

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Jessica L. Gustafson is a founding shareholder of The Health Law Partners, P.C. Admitted to the bars of both Michigan and New York, she practices in the firm’s Farmington Hills, Michigan, headquarters. She devotes a substantial portion of her practice to representing providers and suppliers in the Medicare, Medicaid and other payor audit appeals processes. She also regularly assists clients with compliance and reimbursement matters, issues surrounding Medicare enrollment, and other health care regulatory matters. Representative clients include hospitals and health systems, physicians, hospices, home health agencies, and other health care providers and suppliers. Ms. Gustafson is a frequent speaker to legal and health care provider and supplier audiences nationwide. She is also a frequent contributor and author to various health care and health law publications. She currently serves as the Co-Chair of the American Bar Association Health Law Section Membership Committee and a Vice Chair of its newsletter publication, ABA Health eSource. Abby Pendleton is a founding shareholder of The Health Law Partners, P.C. Admitted to the bars of both Michigan and New York, Ms. Pendleton practices in the firm’s Farmington Hills, Michigan, headquarters as well as in its New York location. Ms. Pendleton has been practicing health care law since 1996. She regularly provides counsel to health care providers, suppliers, and organizations in a number of areas, including but not limited to government investigations; fraud and abuse; compliance; reimbursement; payor audits; HIPAA; and physician staff privilege and licensing matters. Ms. Pendleton also specializes in legal issues impacting billing and management companies, anesthesia and pain management providers, hospice providers, and mental health agencies. Ms. Pendleton is a frequent speaker and author on a multitude of health care legal topics.

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