Appealing Charges Connected With Medical Procedures

Posted by Mary Skinner

Question:
My client injured their right knee in a 2004 car accident. The client was treated with arthroscopic surgery and physical therapy for about nine months followed by a right knee replacement short after. In 2006, the client became Medicare eligible and had their knee replacement removed due to an infection, and then replaced with a second prosthesis. From there he had DVT treatment and related vascular care. Also, he had a totally unrelated fall with a hip fracture and replacement in 5/2008. Although the clients knee injury's infection and subsequent two surgeries were alleged as damages in the law suit, causal connection was very weak and we settled the case for $90K. I objected to CMS initial reimbursement amount. Its final repayment demand of $49K will leave the client with practically no recovery. Please answer the following questions: 1. Why won't CMS remove the unrelated hip fracture charges? 2. What is the best strategy to appeal the charges for the tenuously connected medical procedures and hip fracture?

Thanks in advance,
New York Attorney

Answer:
First and foremost, the final demand must be paid back to Medicare within 60 days of the issue date otherwise interest will accrue regardless of any future arguments you present to Medicare.

Medicare will remove the unrelated hip fracture charges if you provide them with documentation that states the charges are not related to your clients’ 2004 injury. As or a strategy to appeal the other charges, the best approach would be to request a post settlement compromise and provide any documentation you can to support your argument. Given the settlement amount and Medicare's demand it has been our experience that Medicare will usually do a 1/3 split between all parties.

Mary Skinner