Steven Greenspan from EHR, tells you exactly how to handle these odd ALJ decisions from early 2013…
For your convenience, the transcript of my portion of this video appears beneath the player. (Does not include interviews.)
Click the image below to start the video if it does not auto-start.
Welcome everyone, I’m Ernie de los Santos, founder of Appeal Academy and author of INSIDE RAC SUMMIT, Insights and Highlights from the Seventh National RAC Summit. Thanks for stopping by and watching my new video and this, our fourth interview in this series. Today you’re in for a great, short explanation of some very strange decisions that have come out of the ALJ appeals level, lately — decisions that fly in the face of CMS regulations.
Since January, 2013, some providers have received some very oddly worded decisions from one particular Administrative Law Judge. The decisions seemed to indicate that the Judge did not understand the proper process for dealing with these appeals for Medicare Part A denials based on medical necessity. The Judge awarded a “Wholly Favorable” decision, but at the same time, said that the words “observation” and “inpatient” in the cases before him were indistinguishable, and therefore could be interpreted to mean “observation.” He went on to say that the only difference between them was the amount to be paid for each, which meant that he had no authority in the case, and therefore remanded the claim back to the previous level, with instructions for them to determine how much to pay.
I talked with Steven Greenspan from EHR, who was very familiar with the situation, as you will see, in the interview. Steven is not only a lawyer, but he has a special degree, specifically in healthcare law. All that to say, he has a unique viewpoint, one you need to hear. Steven tells you exactly how to handle these decisions, so you’ll know exactly what do you do now if you have one, and what should you know to be ready for one of these if you get one.
If you’ve been watching the previous videos, you will now know what you should do now to avoid getting a decision like this.
But let’s listen now to what Steven had to say…
[interview here – click on the player above to hear it all]
So there was some good news there, anyway. The bad news is that if you get one of these, you may have to take it up to the fourth level of appeal, the D-A-B, but as Steve suggested, you might want to make some phone calls first, and see what happens. Regardless, you still have your appeals rights, intact.
That’s all for today, watch for your next email, and I’ll hopefully have my next interview available.
In the meantime, good luck with all your appeals.
I’m Ernie de los Santos, for Appeal Academy, thanks for watching.