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Alexandria medical practice sues Health and Human Services, Medicare over billing dispute


By Tomas Kassahun | Sep 18, 2018

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ALEXANDRIA – Mchael Dole, MD, A Professional Medical Corporation (APMC) based in Alexandria, recently filed a federal a lawsuit against the U.S. Department of Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services (CMS) regarding a dispute over Medicare receivables claims.

The lawsuit filed in the U.S. District Court for the Western District of Louisiana on Sept. 11 asks for injunctive relief to stop CMS from withholding Medicare payments from APMC for ongoing services following an overpayment audit.

APMC said the withholding should be stopped until it has been give a reasonable time for a hearing before an administrative law judge. 

The APMC is a professional medical practice participating in the Medicare program providing medically necessary services to Medicare beneficiaries in and around Alexandria. APMC submits claims for payment to HHS, which processes said claims through CMS’ contractors, the lawsuit states. 

According to the lawsuit, medical providers give services to a Medicare beneficiary and the providers then submit a claim for reimbursement to a designated Medicare administrative contractor.

The APMC said it’s seeking a preliminary and permanent injunction preventing the defendants from collecting “any more of the $4,339,672.96 and $9,268.48 in alleged overpayment amounts, plus interest until it has been afforded a meaningful opportunity to exhaust all administrative remedies.” 

The lawsuit asks for the court to enter an order “requiring defendants to provide the APMC a hearing before an administrative law judge.”

The lawsuit said the billing dispute is premised entirely upon a CMS contractor’s incorrect post-payment application of CMS’s non-binding, inconsistent guidance and flawed clinical determinations of physician care made by persons who are not physicians.

Defendants, HHS and CMS, have launched a scheme, where they have created a system of using outside auditors such as recovery audit contractors and zone program integrity contractors (ZPIC) to reopen and deny past paid claims, the lawsuit adds. “These auditors are in addition to the Medicare administrative contractors who receive and adjudicate claims in the first instance,” the lawsuit stated.

According to the allegations, the recovery and zone contractors have been awarded contracts worth millions of dollars to identify as many claim denials as possible on post-payment review.

“They use methods, including statistical sampling and extrapolation, for CMS to take millions of dollars in Medicare receivables currently owed to providers based on much smaller base amounts attributed to a small number of past claims,” the lawsuit states.

APMC said the Medicare contractor Novitas Solutions Inc. first approved payment of the claims in dispute and the APMC received payment for the medical services rendered.  

“Later, the APMC was subjected to two post-payment review audits conducted by CMS, through its ZPIC contractor, AdvanceMed, for claims that had been previously approved by Novitas and paid to the APMC,” the lawsuit stated.

According to the lawsuit, AdvanceMed determined that $10,466.84 in claims were overpaid to the APMC and extrapolated that amount to $4,339,672.96. In the other post-payment review, according to the lawsuit, AdvanceMed determined that $9,268.48 in claims were overpaid to the APMC, but did not extrapolate that amount.

The APMC said it has timely appealed AdvanceMed’s determination in accordance with the appeals process as outlined in the Social Security Act. 

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