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Reimbursement Page By Joe McTernan, AOPA government affairs department
ALJ Hearing Success Strategies Critical steps for defending your claim
Editor’s Note: Readers E! QUIZ M of Reimbursement Earn 2 Page are now eligible Business CE Credits to earn two CE credits. SEE PAGE 18 After reading this column, simply scan the QR code or use the link on page 18 to take the Reimbursement Page quiz. Receive a score of at least 80 percent, and AOPA will transmit the information to the certifying boards.
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O&P Almanac MARCH 2014
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he Office of Medicare Hearings and Appeals (OMHA) recently announced that it was suspending the assignment of new requests for Administrative Law Judge (ALJ) hearings for a minimum of 24 months—a grave concern to AOPA and its members. While AOPA continues to fight for the preservation of its members’ due process rights under the law, the significant delay in assignment of new hearing requests underscores the need to ensure you, as the practitioner, are fully prepared to defend your claim when granted a hearing with an ALJ. This Reimbursement Page will focus on the ALJ process and how best to prepare for a successful outcome. The ALJ hearing is the third level in the formal Medicare appeals process. It follows redetermination, which is performed by the contractor who made the initial determination; and reconsideration, which is performed by a single contractor known as the Qualified Independent Contractor. While redetermination and reconsideration decisions must be based on published policy, the ALJs have significantly more leeway in rendering decisions as they are not strictly bound by policy but rather by the framework of the law. Many claims that have been denied through redetermination and reconsideration are found to be valid and payable by the ALJ because they fall within the Medicare coverage guidelines as described in the Social Security Act.
Preparation Is Key You should begin preparing for a successful ALJ hearing long before the request for or scheduling of the hearing takes place. It should begin during your first encounter with the patient. Anything and everything that occurs from this moment forward may ultimately play a role in determining your success or failure at the ALJ appeal. While it is virtually impossible to understand the impact a decision may have on the outcome of a hearing several years down the road, taking small steps from the beginning to ensure that you have the proper support for your claim may make all the difference when the case is presented to the ALJ. 1. Obtain documentation. The most important thing you can do to prepare for future scrutiny of your claim is to make every effort to secure written documentation from the referring physician that supports the medical need for the orthotic or prosthetic device you are providing. The need for physician documentation is a critical component of the process, and the lack of it is by far the single most common reason why claims are denied, especially at redetermination and reconsideration levels. Obtaining this documentation can be frustrating as it holds you accountable for the actions of others. While there is no sure way to force physicians to document the information that is expected to be in their records, a small bit of