Note from the speaker: Guidance on Medicare hearings from a former Administrative Law Judge

Wednesday, September 26, 2018

By Alicia Kutzer, Esq., LLM, MHA

It is critical for providers and any person who is involved with healthcare revenue integrity to stay as current as possible or risk losing out on opportunities to ensure proper and full payment of millions of dollars’ worth of billed and/or billable claims, and the National Association of Healthcare Revenue Integrity’s (NAHRI) 2018 Revenue Integrity Symposium (RIS) can help professionals do just that.

RIS will be held October 16–17 at the Wigwam Resort in Litchfield Park (Phoenix), Arizona and is filled with a fantastic lineup of subject matter experts who spend significant amounts of time researching and working in areas that impact revenue integrity. The importance of listening to subject matter experts cannot be understated because it lends itself to developing an ability to anticipate and forecast what tomorrow’s issues will be, thereby resulting in streamlining and prioritizing policies and procedures that need to be operationally implemented as soon as possible to preempt an avoidable risk of loss.

Medicare hearings from the ALJ perspective

I always enjoy the opportunity to speak to other healthcare professionals and I am looking forward to speaking at RIS. I will be presenting two topics, both of which have been evolving especially over the last few years. The first session that I will be conducting is called “An Insider’s Guide to Medicare Fair Hearings,” which is scheduled for Tuesday, October 16 at 1:45 p.m., and the second session that I will present is titled “Medicare’s Secondary Payer Provisions: What Every Provider Needs to Know,” which is scheduled for Tuesday, October 17 at 8 a.m.

I have found that both topics are usually considered complex and somewhat intimidating to providers and healthcare professionals. I’m excited to leverage my experience and ongoing research to disseminate easy-to-understand meaningful information. It is my expectation that the Administrative Fair Hearings session will serve to assist providers with respect to their efforts to be paid for claims that are denied either through prepayment or postpayment audits. Medicare Secondary Payer (Third-Party Liability) issues are currently undergoing significant changes through CMS’ renewed focus and efforts to recoup money paid as conditional payments and through current litigation that is proving to be a considerable risk to providers.

Having adjudicated countless Medicare Secondary Payer appeals and represented the Qualified Independent Contractors (QIC) at thousands of Administrative Law Judge (ALJ) hearings as well as presiding over countless—well, at least I haven’t counted—Pennsylvania Medicaid hearings as an ALJ, my understanding of the adjudicatory process and how to confront issues that face providers in these subject matters is useful to healthcare professionals who are interested in improving a provider’s “bottom line” while at the same time adhering to regulations.

My must-attend session

For me, one of the must-attend sessions at RIS is “Walk in the Shoes of a Compliance Investigation,” presented at 11 a.m. on Wednesday, October 17 by Melissa J. McCarthy, RHIT, CCS, CHC, and

Greg Radinsky, JD, MBA, CHC, CCEP, both of Northwell Health in Great Neck, New York. This presentation is particularly compelling to me based on my experience in the world of government payer appeals. As an attorney and former Administrative Law Judge, I am always interested in better understanding the perspectives of those involved in the same area of healthcare law that I have had the exciting opportunity to be involved in for nearly a decade. Another reason I am looking forward to this session is that as an instructor for HCPro’s Medicare Boot Camp® — Audits, Appeals, and Denials Version, this session may provide some additional topics that could one day be incorporated into the boot camp and/or topics that may arise during boot camp discussions. 

Going back to Phoenix

I grew up visiting Phoenix roughly once or twice each year, but I have not visited in nearly 20 years, so it is going to be nice to get back there. I am hoping to visit Old Town Scottsdale and maybe get dinner at one of the many restaurants on or near the Arizona State University campus, which is in downtown Tempe. I remember really enjoying these two places, and luckily both of them are close to Phoenix.

I hope you see you at the conference!


Editor’s note: Kutzer is an adjunct instructor for HCPro’s Medicare Boot Camp®—Audits, Appeals, and Denials Version and Medicare Boot Camp®—Hospital Version. Kutzer is a licensed attorney in the state of Pennsylvania and is a managing partner of Kutzer Law Firm, LLC, located in the Wilkes-Barre/Scranton area, founded in 2011. She served as an Administrative Law Judge in more than 1,000 Administrative Fair Hearings for Federal Hearings and Appeals Services, Inc., from August 2016 through February 2017. Prior to that, Kutzer was a post-adjudication appeals officer, appeals officer, and subject matter expert for MAXIMUS, Inc., a Medicare Qualified Independent Contractor (QIC), from April 2012 through November 2015.

For additional information, listen to a recording of our Revenue Integrity Symposium Demo and view the corresponding slides. Revenue integrity professionals wishing to earn support from program administrators to attend the 2018 Revenue Integrity Symposium may adapt our justification letter proposal.

Found in Categories: 
Denials and Appeals, Revenue Integrity