Status House Well being Care filed a lawsuit in opposition to the U.S. Division of Well being and Human Providers (HHS) on January 9. The corporate claims a flawed Medicare appeals course of brought about it to endure tens of millions of {dollars} in damages.

Status House Well being Care is predicated in Chicago and serves 12 counties in Illinois. It presents residence care, personal nursing and occupational remedy.

The lawsuit states that between 2015 and 2019, Status underwent a post-payment audit of 33 claims for companies submitted to Medicare. Following the audit, AdvanceMed Company, the HHS contractor, alleged that 91% of the claims reviewed didn’t meet Medicare protection standards, leading to an overpayment of greater than $2.5 million.

Status challenged the alleged overpayment by way of the HHA administrative appeals course of, which the corporate stated was topic to “delay, mismanagement and incompetence,” as acknowledged within the criticism.

Suppliers sad with an opposed claims determination can problem it by way of a four-step administrative appeals course of. The steps embrace redistricting, reconsideration, a listening to earlier than an administrative legislation decide (ALJ), and a overview by the Medicare Appeals Council.

On this case, the ALJ assigned to the enchantment dominated in opposition to Status. In reviewing the choice, the corporate alleged that the ALJ copied findings from an earlier appellate determination.

“This can be a blatant violation of relevant laws requiring ALJs to overview instances de novo and make impartial findings of reality and conclusions of legislation,” the lawsuit stated.

Status then appealed to the Board, contesting the ALJ's determination. After 90 days with out a determination, the corporate invoked its proper to bypass the board and escalate the case to federal court docket. As an alternative of granting this request, the Board remanded the matter to the ALJ.

The ALJ addressed the problems outlined within the pretrial detention order with out additional proceedings and remanded the case to the Board. After one other 90 days, Status tried to re-escalate its enchantment to federal court docket. As an alternative of approving that request inside the 5 days required by company laws, the board took 11 months to verify that the corporate had the best to escalate the matter, the criticism exhibits.

Throughout this enchantment process, curiosity of 10.625% per yr was accrued on the alleged overpaid curiosity.

Status is now in search of an order from the U.S. District Courtroom for the Northern District of Illinois declaring the company's last determination “illegal, unsupported by substantial proof, and arbitrary and capricious.” The Firm additionally requests that every one damages, fines, prices and attorneys' charges be awarded to the utmost extent permitted by legislation.

“Typically talking, it’s uncommon for an enchantment to proceed to the district court docket degree,” Angelo Spinola, co-chair of the House Well being, House Care and Hospice apply at Polsinelli, informed House Well being Care Information. “There are 5 phases of enchantment, and it’s common for choices on massive overpayments to be appealed, at the least within the first few phases, particularly if there’s stable proof displaying that the extrapolation of overpayments is inaccurate . These appeals typically obtain affordable success within the type of overpayment changes or, much less generally, chargebacks. Nevertheless, as soon as a supplier reaches the much less frequent fourth and fifth phases of enchantment, the chance of reversal decreases.”