Hello List!
Here is the original question:
I am wondering if there are legal grounds for us to file claims in Small
Claims Court based on the fact that Medicare clearly violated our right to
speedy ALJ appeal. Certainly I understand that each jurisdiction has
different limits for small claims. Here in New York City it is $5000 and I
believe they allow up to 5 commercial claims per year. So, it will be
insufficient to handle high ticket items like C-Legs, etc, but I am sure
each of us have a few claims that would fit in this category. I would
request hearing by judge and demand that Medicare vacates its decision on
audit solely based on the violation of their own rules and regulation
regarding the right to appeal. Imagine, if all of us file 5 such claims in
various courts? This will create a precedent and further jam the broken
system, thus, hopefully leading to a favorable resolution. Am I crazy? Your
thoughts?
Replies:
The ALJ level has 90 days to make a decision; when they fail to do so,
providers have a right to request escalation to the Medicare Appeals
Council (level 4). They have 180 days to make a decision; if they fail to
do so, providers can then file a civil suit in Federal Court (level 5).
Because we are dealing with a federal agency, any legal action has to be
brought to a federal district court. The good thing is that federal court
is already level 5 of this crazy appeals process. However, I have yet to
hear of any provider getting this far. I have one appeal that is getting
close; its pending at level 4. But I plan to file a civil suit in level 5
regardless of the outcome.
And I 100% agree with you that all providers need to file legal action
against Medicare. The only way to get out from under this Medicare umbrella
is to go through federal court.
I believe you can only take govt to court in superior court or federal
court.
You cannot sue the federal government in state court. You can only sue the
federal government or a federal agency in federal court.
reference: http://www.courts.ca.gov/9617.htm
If your ALJs have not remanded a decision in 90 days, you can request
escalation to Level 4 appeal at Medicare Appeal Council. There is
information on the OMHA website about what you need to do and info in the
42 C.F.R. I you need it, I can scan and email you what I have.
After the Medicare Appeals Council has your case, they have 180 days to
process it. The next level after that is Federal Court.
First of all, I know nothing about small claims courts but my initial
thought is…genius! If everyone just took one claim to the court there is
no possible way Medicare would be able to send someone to every case…not
even close let alone try to keep the schedule. Not sure it would all work
but I like your thinking!
Funny you ask this question because I literally looked this up on Sunday.
I looked into taking “Robert C. Thompson”, the auditor at C2C Solutions
for one of our Medicare claims that he found unfavorable (illegally).
After I researched the guidelines for small claims court, I found out
small claims court only handles certain types of claims. It said that you
could not file a claim if it was in regards to an “assigned claim”.
Since we did accept assignment on the Medicare claim, I assumed I was not
able to file a claim with the small claims court for our county (Harris
County) which is in Houston, TX. However, please let me know if you find
any loopholes or if I misunderstood what I read. I did file a formal
complaint with URAC which I think is the company who provides the
accreditation for them. They responded quickly and I sent them all the
paper trails (blocking out the patient name or any patient identifiers).
Thank you all!
*Dr. Stephan R. Manucharian, CP, BOCO, LP(NJ), FAAOP*
*Doctor of Health ScienceClinical Director Orthopedic Arts Laboratory,
Inc.141 Atlantic Ave., Brooklyn, NY 11201718-858-2400; Fax:
718-858-9258;http://www.OrthopedicArts.net
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