Hospice & Palliative Care

Representative Experience

• Represented hospice in appeal of a Medicare audit that resulted in an extrapolated overpayment of more than $12 million. Advocated for the hospice through the appeal process including a hearing before an administrative law judge. The extrapolation was thrown out and the ALJ returned a fully favorable ruling, resulting in a final overpayment amount of $0.00.
• Through administrative appeal process, decreased alleged $8.6 million hospice client's overpayment identified during Medicare audit to less than 1 percent: $77,000.
• Appealed alleged overpayment finding during Medicare audit that placed nonprofit hospice client on brink of ceasing or selling operations, reducing overpayment by approximately $20 million.
• Successfully argued for hospice client that Unified Program Integrity Contractor (UPIC)'s $25 million extrapolated overpayment was invalid. At first level of appeal, hospice was vindicated leaving mere $70,000 in dispute.
• Negotiated a $2 million settlement of a $25 million UPIC audit securing the hospice's future and its service to the community.
• Through advocacy, secured non-intervention decisions by government prosecutors and subsequent case dismissals in numerous qui-tam whistleblower lawsuits across the country.
• Secured elimination of $4.4 million extrapolated overpayment demand by UPIC. At reconsideration level of appeal, successfully argued that statistical extrapolation was fundamentally flawed and Qualified Independent Contractor (QIC) agreed that methodology was invalid.
• Secured withdrawal of $15 million extrapolated overpayment demand by UPIC. Prior to filing first-level redetermination appeal, successfully argued that payment demand must be rescinded due to fundamental flaws in statistical extrapolation. Achieving withdrawal at this early stage allowed client to avoid years of costly litigation and, due to appeal backlog, the threat that multimillion recoupment would begin before case was heard by administrative law judge (ALJ).
• Secured withdrawal of $12 million extrapolated UPIC audit finding before demand letter was issued. Almost immediately persuaded Medicare Administrative Contractor (MAC) and UPIC that fundamental errors were made in audit documentation review, rendering overpayment determinations and statistical extrapolation inaccurate. The hospice was thus able to avoid costly and time-consuming appeal.
• At first level of appeal, successfully overturned 84% of UPIC claim denials and secured removal of extrapolation, reducing $7 million repayment to nearly $96,000.
• Secured removal of extrapolation decision for hospice resulting in reduction of overpayment from approximately $6 million to approximately $100,000.
• Successfully defended one of the first federal hospice Medicaid Integrity Contractor (MIC) audits by obtaining withdrawal of nearly entire $3 million overpayment. Coordinated with local counsel to challenge State's ability to recoup Medicaid nursing home room and board dollars on basis that Medicare hospice services were alleged to have not been medically necessary.
• Received favorable decisions from ALJ on all beneficiary denials appealed in extrapolated sample, reducing overpayment from approximately $4.6 million to just under $40,000.
• Successfully defended state Medicaid audit seeking to recover $6+ million in nursing home room and board pass-thru payments. After initial response, recoupment was reduced to ~$82,000.