Bass, Berry & Sims attorney Anna Grizzle discussed a March 2018 decision by the U.S. Court of Appeals for the Fifth Circuit allowing healthcare providers to retain their money throughout the entirety of a Medicare claims appeal. Prior to the Fifth Circuit ruling, providers were required to return claims payments before having an opportunity to appeal the claims decision.

“The Fifth Circuit opinion is an acknowledgment that the Medicare appeals process is broken,” Anna stated. “The years-long delay for an ALJ [administrative law judge] hearing causes an extreme hardship for providers fighting flawed audit decisions. They have to pay back the alleged overpayment before having an opportunity to be heard, even when they have strong evidence that the claims denials were in error. Providers facing large repayment demands or small providers without access to capital are often forced out of business. This result is fundamentally unfair, especially when considering these providers will likely win an appeal of the audit decisions when considering the high success rate of these appeal. As long as the Centers for Medicare & Medicaid Services fails to fix the Medicare appeals process, more providers are likely to use the Fifth Circuit’s opinion to seek protection from the courts against the ‘draconian’ recoupment process.”

The full article, “Providers Notch a Victory Over Medicare Enforcement Efforts,” was published in the Bloomberg BNA Health Law Resource Center on April 6, 2018, and is available online (subscription required).