News About The Strange ALJ Decisions Recently Delivered

In early spring of 2013, providers saw some very oddly worded decisions from at least one ALJ judge.

For your convenience, the transcript of my portion of this video appears beneath the player. (Does not include interviews.)

Hello everyone and thanks for stopping by again and listening in.I’m Ernie de los Santos, Founder and Faculty Chair of Appeal Academy, and author of “INSIDE RAC SUMMIT” my review of the 30 presentations from last December’s National RAC Summit.Today, I’m again not wearing my RAC Shadow Supervisory Special Agent hat, but again want to talk about some recent ALJ decisions that have caused quite a stir.

I hope you listened to my last video and have started doing the three things I advised you about there – you joined the free rac-relief Google Group, you watched the free interview I did with Drew Wachler about how to get paid even when you lose an appeal for a part a claim, and you’ve downloaded part 1 of my 80-page report, INSIDE RAC SUMMIT. If you didn’t get to hear me explain those three things and why you need to do them right away, I’m putting a link on the screen below, so you can go over there and watch that video. If you don’t want to do that now, I’ll give you the link again, at the end of this video, so don’t worry. I think it’s that important, and as I’ve explained before, I want to help providers because I think CMS is giving you a raw deal. I have the tools and talent to help, so that’s why I’m doing this.

Oh… And now, here is the link for you to get the complete version of “INSIDE RAC SUMMIT”. I’ll also send you a link by email, later.

Anyway, today, in this short video, I want to talk about something that was burning up my email box last week, courtesy of the rac-relief Google Group. Let me just give you a short idea, in case you haven’t heard about this already.

Over the past few months, some providers have started receiving some very oddly worded decisions from at least one particular administrative law judge. And those same decisions seemed to indicate that at least one ALJ judge did not understand the proper process for dealing with these appeals for part a denials based on medical necessity. I might be oversimplifying it here, but in the interest of time, I’ll just say that what the judge was doing was giving a ‘wholly favorable” decision, but at the same time, he was saying two other things, that were flatly wrong. First, he was saying that the words “observation” and “inpatient” in the cases he had before him were indistinguishable, and that the word inpatient, although in fact in the documentation, could be interpreted to mean observation. Of course that’s completely contrary to what CMS regulations say. Second, he was saying that since observation and inpatient are basically the same thing, then the only difference between them is the amount to be paid for each, which makes them merely payment categories. He then states that since all payment amounts are purely the responsibility of the secretary, he has no authority to stipulate how much should be paid for the claim, and therefore remanded the claim back to the q-i-c, with instructions for them to determine how much to pay.

Evidently, many hospitals have received decisions like this, and are wondering what to do with them. So, I started calling some of my contacts at various places, and I was able to get some good information on how these experts would handle these decisions. That is, what do you do now if you have one, what should you know to be ready for one of these if you get one, and what you should do now to avoid getting one like this.

So. I recorded several interviews and I’m going to post them here at Appeal Academy for you to hear.

Now, not all of them are about the issue I just mentioned, but they speak to how our industry is being sold to congress as a bunch of frauds and crooks, that overbill Medicare so much that when we get caught by auditors, we can only argue with them less than 3 percent of the time. That is, CMS is so good at catching us that they are only wrong 2.4% of the time.

So. The first one, which I’ll play in just a minute, is from a phone call I had with dr. Ron Hirsch, from accretive health services out of Chicago. Dr. Hirsch is going to tell you about what he suggests you do to help yourself and all hospitals, a way to appeal just about everything, in an effort to, first of all, protect your rightful reimbursements, and second, to debunk the BS that CMS is telling congress.

Now let’s listen to some of that call — there’s no intro here, I just let Dr. Hirsch start telling me about what he is suggesting to you all…

[interview here]

Ok, so that’s what Dr. Hirsch had to say, and I appreciate him letting me share that with you all. One thing that probably pops into your mind right away, however, is this — how do I do that? How do I make sure I have an appeal letter that in fact is both sufficient and effective, to at least hold my place in line, to get to the ALJ level?

It would be nice if you had a template for that, right?

Well I had the same question – so I called some people I know who are good at teaching how to use templates for appeal letters – the folks at appeal masters.

So I called them, and tomorrow, I’ll post that interview, from a call with Renee Leary, of Appeal Masters, out in Maryland. Renee gives you some great advice about how to write simple but effective “spacer appeals” – a term she uses to describe an appeal that is used as a “spacer”, to kind of hold your place in line on the way to an ALJ appeal, a level 3 Medicare appeal.

Watch for my next email, and I’ll give you that link, to another short interview.

And — there will be another one, probably the next day after that, where I interview Steven Greenspan, from EHR, where he tells me about exactly what to do to handle those strange appeals, like I mentioned at the beginning. In fact, Steven is handling several of these cases, and has even gone directly to the chief ALJ, the honorable Judge Nancy Griswold, to get help.

Finally, I’m waiting to hear from another law firm, who has been talking directly with CMS about these appeals, how CMS interprets the situation, and will have great information on what to do with them, if you get any, now or in the future.

So stay tuned, for more great content, from Appeal Academy.

I’m Ernie de los Santos, thanks for watching.

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