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Healthcare provider overturns Medicare overpayment determination, resolves revocation

A healthcare provider of family and internal medicine received a notice from CMS/Medicare revoking its ability to bill Medicare for an alleged “pattern of fraud and abuse” relating to submitting bills for deceased patients and/or submitting bills for patient visits on dates when the visits could not have occurred. The provider also received an overpayment notice from Palmetto GBA (the Medicare Administrator) in excess of $600,000. These were both in context of separate UPIC audits.

Waller handled the administrative appeal on both fronts, including multiple rebuttals, requests for reconsideration, and Departmental Appeals Board (DAB) / administrative law judge (ALJ) appeals and years of correspondence with the UPIC auditors, Palmetto GBA, and CMS. Waller successfully overturned that vast majority of claim determinations on the overpayment appeal (proving medical necessity and proper billing to the satisfaction of the UPIC auditor and CMS) leading to an approximate 90 percent decrease in the overpayment demand. Waller was also able to resolve the Medicare revocation issue to the satisfaction of the client. All of Waller’s efforts also successfully protected the National Provider Identification number (NPI) of the individual physician owner of the practice.

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Jeana Clark
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