Tampa Medicare Attorney for Claim Denials, Overpayments and Appeals
A denied Medicare claim is a payment problem until it becomes a pattern. One denial costs you the claim. A run of denials for the same service can invite a probe, prepayment review or an overpayment demand on claims Medicare has already paid. If your practice or facility in Tampa Bay is seeing denials, you need a Tampa Medicare attorney looking at why before the contractor decides what they mean.
The Health Law Offices of Anthony C. Vitale, now practicing as Vitale, Suarez & Associates, P.A., is a Florida healthcare law firm founded in 1982. Its office is in Miami Lakes, and it represents providers throughout Florida, including the Tampa Bay area, in Medicare denials, overpayments and appeals.
Why Medicare Claims Get Denied
- Medical necessity is not documented in the record
- The claim does not meet the criteria of a Local or National Coverage Determination
- Orders, signatures or certifications are missing or late
- Coding or modifier errors
- No response, or an incomplete response, to an additional documentation request
Many denials are documentation problems before they are coverage problems. A long note does not prove a well-supported claim.
When Denials Turn Into Something Larger
A high denial rate is data, and contractors act on data. Repeated denials can lead to Targeted Probe and Educate, prepayment review, a post-payment audit of claims already paid or a referral to a program integrity contractor. If the review uses a sample, the error rate can be extrapolated to claims no one has looked at. By the time a demand arrives, the denials you did not appeal are part of the pattern.
Reopening or Appeal?
A reopening can correct a clerical or minor error without a formal appeal (42 C.F.R. § 405.980). It is not a substitute for an appeal when the denial is about coverage or medical necessity, and it should not be relied on to extend an appeal deadline.
- Redetermination by First Coast Service Options, the Medicare Administrative Contractor for Florida. The request is generally due within 120 days of receiving the initial determination (42 C.F.R. § 405.942).
- Reconsideration by a Qualified Independent Contractor. Evidence not submitted at this stage generally cannot be added later without good cause.
- Hearing before an Administrative Law Judge, requested within 60 days of the reconsideration notice.
- Review by the Medicare Appeals Council.
- Judicial review in federal district court, when the amount in controversy meets the annual threshold.
When a denial rests on a coverage determination, the difference matters: ALJs and the Medicare Appeals Council are bound by National Coverage Determinations but give substantial deference to Local Coverage Determinations rather than being bound by them (42 C.F.R. §§ 405.1060, 405.1062).
Strategic Legal Solutions for Healthcare Providers
Who Pays When Medicare Denies Coverage
If a claim is denied as not reasonable and necessary, the limitation on liability provision (42 U.S.C. § 1395pp) can decide whether the provider, the patient or Medicare bears the cost. The answer often depends on what the provider knew and whether a valid Advance Beneficiary Notice was given before the service.
Overpayment Demands
When denials turn into an overpayment demand, the recoupment clock starts with it. Recoupment can begin 41 days after the initial demand unless a valid, timely request for redetermination stops it (42 C.F.R. § 405.379). An extended repayment schedule is possible in some cases, but it is not automatic.
Frequently Asked Questions
Should I appeal every denied claim?
Not necessarily. The cost of an appeal should be weighed against the claim, but a pattern of denials for the same service deserves attention even when each claim is small.
What is the difference between a reopening and a redetermination?
A reopening corrects an error in a determination and is at the contractor’s discretion. A redetermination is the first level of the formal appeal process, with its own deadline and record.
Can I bill the patient for a denied claim?
Only in limited circumstances, generally when a valid Advance Beneficiary Notice was given before the service. Review the denial and the notice before sending a bill.
Does the firm have an office in Tampa?
The firm’s office is in Miami Lakes. It represents healthcare providers throughout Florida, including the Tampa Bay area.
The owner of a Tampa, Florida-area medical marketing company was sentenced to 70 months in prison today for his role in a $2.2 million Medicare fraud scheme involving the payment of kickbacks and bribes to fraudulent medical clinics in Miami in exchange for the referral of Medicare beneficiaries for expensive genetic tests that were medically unnecessary, and for his role in the illegal structuring of cash withdrawal transactions.
Assistant Attorney General Brian A. Benczkowski of the Justice Department’s Criminal Division, U.S. Attorney Maria Chapa Lopez of the Middle District of Florida, Special Agent in Charge Michael McPherson of the FBI’s Tampa Field Office and Assistant Inspector General Omar Perez of the U.S. Department of Health and Human Services Office of the Inspector General’s (HHS-OIG) Miami Regional Office made the announcement.