Lessons Learned From the Administrative Law Judge Process

© 2024 HMP Global. All Rights Reserved.
Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of Podiatry Today or HMP Global, their employees, and affiliates.

So, my name is Dr. David Freedman. I'm a podiatrist. I practice in Silver Spring, Maryland. I've been in practice 37 years plus at this point in time. I graduated from what was called Pennsylvania College of Podiatric Medicine, which is now Temple, and I've been involved in my practice growing it to become also now a single specialty 22-state practice. I do currently reside as the APMA coding chair. I've been a member of the coding committee at APMA since 2005. And the reason why that's important is that it, my history is that I did a lot of education in coding compliance prior to that and then subsequently was elevated to that level of being on the committee and then have been the chair for the past about five years. I am a board member of US Foot and Ankle Specialists. We've been in practice as a group since 2011, originally it's Foot and Ankle Specialists of the Mid-Atlantic and I was a chief compliance officer. So I've had a lot of experience in reviewing thousands of records, understanding medical data, and I serve as a certified professional coder, a certified surgical foot and ankle coder, a certified professional medical auditor, compliance auditor for my group, and I do this on a consulting basis for many practices around the country currently as well. I also do services with our local Medicare carrier known as Novitas, and I am the Carrier Advisory Committee member representative, been that way for many years as well.

What is the general pathway that brings one to the ALJ stage of review?

So every MAC, Medicare administrative contractor, has to have an option for appealing

a claim. And the first level is called redetermination. So, if I have a claim, it gets denied unjustly, I can deny it back to the Medicare contractor and say, hey, I don't feel this was denied appropriately. You have 120 days from your day to your service from that initial claim determination that they sent you that you can file an appeal. And then once you file that appeal back to your MAC, you then can expect to receive a response or decision back within 60 days of that request.

Now, what a lot of doctors fail to realize is that every Medicare contractor has local carrier determination policies and local carrier billing policies on their website. And a lot of people don't even look at them. They don't even know all the ins and outs. It's so important if you bill services to your specific Medicare contractor that you go to their website, not to someone else's website, because a lot of times the policies at one Medicare contractor may not be applicable to another contractor's website. So even though it's Medicare and supposed to be all the same, it's not all the same when it comes to policy because the purpose of the local carrier determination policies is to actually limit utilization and then the billing policies are also they're in place to make sure you only use their specific diagnoses that they feel are relevant to the treatment that's being provided. So these things are necessary for the doctor, staff, billing site, revenue cycle management people, anyone that's involved in billing in the practice, the doctor itself, to make sure everything is all coordinated appropriately. So medical records have to be looked at, reimbursement policy has to be looked at, all this has to be looked at and make sure the medical policy is being followed. And that's just called redetermination.

The second part after that is that if it's denied, you do have an opportunity to have what's called redetermination of that determination. And the MAC has, again, 60 days from when you receive your denial, you turn around and they'll give you a short period of to ask for a redetermination, but they have, again, another 60 days to physically respond to your request for overturning the denial. And in these situations, you’ve got to make sure that you have all your ducks in a row, that you've given them all the medical records, see what was lacking in the documentation to see what would be appropriate for overturning the determination to be incorrect. Sometimes it's just that their computer systems are off and the doctor's practice gets dinged for that even though they shouldn't have been. So that's where sometimes myself, like as a carrier advisory committee representative, goes to the specific MAC and we say, "Hey, this should not have been denied "because the code is covered for podiatry."

And they may sometimes accidentally leave off our and that's the only reason why something is not covered. If for some reason the redetermination doesn't work out for the provider, they can go on to reconsideration. That's supposed to be something called a de novo review, which means supposed to be a whole new review. And it's performed by something called a quick or QIC. They are another separate contractor unrelated to the Medicare Administrative Contractor that you send your claims to initially, and they're supposed to be separate. But I can tell you from my experience that a lot of times they don't change or vary from the actual Medicare contractor’s review. They actually, I think over 80% of the time, follow them. So, the doctors are required to do this if they want to appeal the claim. It has to go all the way through this process. They then, same thing, have 60 days to respond to your reconsideration request. And you’ve got to make sure you try to provide all documents during the reconsideration to the QIC. Because if you want to go on to the next step, which is administrative law judge, if they don't find in your favor, you want to make sure you submit all your documentation, all your reasons why the services are covered in advance.

And an ALJ hearing, administrative law judge hearing, is your next step. And I have to be honest that even though these other ones often fail, if you really feel deep in your heart, you're right, and you should not have been denied the payment for the services, typically you're going to want an ALJ hearing. And what we tell practice to do is to get the patient involved, if you represent the beneficiary, you can get an ALJ hearing really quickly within two months. If you don't, you request it as a provider. It can take up to two to three years to get that ALJ hearing. So, there's ways around the system to help you get this hearing faster than you would have had you done yourself just as the provider. So, appeal online, they offer portals. There is a portal for the HHS .gov website for sending in what are called OMHA appeals.

There's an ePortal you can follow along in the portal when your ALJ hearing is. And at that hearing, you have to plan to present yourself just like an attorney would. And if you're not sure how to handle yourself, then you need to hire someone who is an attorney in healthcare to help you navigate the ALJ process. And there are people like myself who act as guides, as an expert, as someone who can help navigate this from the podiatric standpoint, as well as from the auditing, compliance, coding side. So, we often help in those cases because sometimes a doctor doesn't know all the correct words to use or all the correct statements to use that are relevant to the policies are on the website and how they provided their medical necessity to make sure that these services that were denied ultimately get paid. We're seeing a lot more of these happen. We're seeing a lot more where they're doing 100% denials. And to me, when you see 100% denials for services, something's not right on the auditing side. So, it's something that I would strongly encourage anyone who is involved in their own CMS Medicare audits and appeals to make sure you follow things through. As I gave, the timeframes are pretty long and these things can drag on for almost a year or more depending on the time frame for the initial appeals all the way up to the ALJ hearing.

What primary features or events might one expect when they do reach the ALJ stage of this process?

The primary events are you have all your ducks in a row. Make sure you have someone either represent you, either whether it's an attorney and or a certified professional medical auditor's key because you need people in your court to explain this to a judge because the ALJ wants to hear the medical reason, the medical necessity, and they also want to hear why the MAC inappropriately denied the claim and how you can explain it to them so they can then follow on and follow the law that Medicare requires them to follow to pay a claim in a hearing such as an ALJ hearing.

What top things can practices do to prepare for the ALJ process?

So, the preparation again requires you back at the QIC level make sure that you provide all your documentation, you need to give a narrative as to what you're providing to them. You literally have to spoon feed them the parts of the appeal, whether it's from a simple thing that's say on page two of the medical record, you will find this on page three, you will find that you need to literally give them the recipe for success. If you just expect to copied records and send it to them and expect for an automatic appeal override, you're not going to probably get it.

So, these people, because they are auditors, they're supposed to know how to review a medical record. Every medical record is not the same. And I've reviewed thousands of records from different practices across the country. And I can tell you that, depending on the electronic medical record system, it doesn't always provide the best way for documentation and you have to sift through the documentation to show where the bullet points of the policies exist and you have to actually break it down, do it paragraph by paragraph, and again a health care attorney often can help you do this. Also an auditor such as myself can do that too. And I really try to find the common ground within all the medical records that have information. A lot of times the auditing bodies will look at one record when really a patient, as we know, is like a book. So you have multiple stories, ie, multiple dates of service. The patient was seeing that create their story that allows for the medical necessity. And so sometimes they don't go back and look at previous medical records. And that's something where we And I'll say, hey, you know, you need to show the patient has their conservative care previously What the requirements were met based on the medical policy? You know, maybe not have been on that one day in a service, but it shows clearly the patient had records over a period of time. So again, preparing for the ALJ is critical because it's just like a court of law. You have to have all your ducks in a row beforehand so that the ALJ can understand what you have and understand from a lay person's perspective because they're not medical persons. They have to read it, understand it based on what you provide them, and then they have applied the law. But if you don't explain to them, they may not understand the medical ramifications of what you provided in your overall care. So, it's important that you have people in your court to help you, and you need good experts to make yourself successful in the long run, and that's really what's important with these. You will be successful if you do have all the right ducks in a row.

Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure accuracy. However, HMP and the speaker do not represent, guarantee, or warranty that coding, coverage, and payment information is error-free and/or that payment will be received.