How to Prepare Your Home Care Agency for State and Federal Audit

How to Prepare Your Home Care Agency for State and Federal Audit

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Dennis Gill: So welcome to CareSmartz360 On Air, Home Care Podcast. I’m Dennis Gill, Senior Sales Consultant at CareSmartz.

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Dennis Gill: Get ready listeners, because today’s guest is not your average attorney. Meet Robert Markette, the legal lifeline for home health, hospice and private duty, home care providers.

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Dennis Gill: Robert is, of course, Counsel at Hall Render, where he’s not just dabbling in the details. He’s diving headfirst into the deep end of Medicare, Medicaid, HIPAA, and everything in between.

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Dennis Gill: So from navigating complex fraud, abuse laws to wrangling with wage and hour issues, Robert is the legal pro. The home care industry didn’t know it desperately needed.

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Dennis Gill: So with over 15 years in the game, he’s developed a reputation for tackling every compliance, twist, and regulatory turn with finesse

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Dennis Gill: audits, check employment policies. You bet government investigations bring it on

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Dennis Gill: whether he’s defending clients in code or helping them breeze through an audit. Robert’s mission is clear to keep homecare providers on the right side of the law while they focus on caring for others.

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Dennis Gill: Let’s get right away. Welcome to the podcast Robert.

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Robert Markette: Thanks for having me. That’s a very kind introduction.

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Dennis Gill: No, no, we’re really glad. We’re really glad that you were able to take out some time for our listeners, and it would be really helpful for them to go through this topic today.

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Dennis Gill: So I’ll straight away deep dive with our questions. The 1st question that we have for you is that what are the primary types of State and Federal audits that home care agencies should anticipate? And how do the focuses differ.

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Robert Markette: So the the primary Federal audits are obviously Medicare. Whether it’s a a smirk, a. You pick the Mac.

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Robert Markette: They come probably looking to take money back and to stay a little similar. You’ll have Medicaid auditors.

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Robert Markette: Medicaid racks, things like that. The focuses can be a little different, most of them, like the smirk, which is a medical review contractor at the Federal level, the the Mac, the Medicare administrative contractors.

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Robert Markette: and most Medicaid auditors. Although the programs vary from state to state with Medicaid are looking at

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Robert Markette: overpayments they’re looking to see. Does your documentation comply with the documentation requirements for the various payment

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Robert Markette: programs? Yeah. So for home health.

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Robert Markette: Do you have your face to face documentation and stuff like that? If it doesn’t, they’re gonna take the money back.

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Robert Markette: The you picks are a little different because they are a uniform program integrity. So they’re looking at fraud. They generally going to come to you on a referral or some some reason they think there’s fraud going on. Their audit focus will be similar in terms of looking at documentation things of that nature.

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Robert Markette: Does documentation meet the requirements.

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Robert Markette: and then and then over broadly the documentation, support, eligibility, etc, and and all the providers look at that, and eligibility with the you pick, because it’s a fraud investigation. That means somebody

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Robert Markette: thinks you’re doing something wrong intentionally. Possibly they may have gotten a tip from somebody. Sometimes you pick autos will come because somebody called the the Medicare Hotline Medicare. Don’t investigate. They hand it off to the you pick.

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Robert Markette: So it’s so the U. Picks a little bit different. If you get a U pick audit, you’re gonna want to consider, you know. Maybe I do need counsel, and the other thing with you picks is they are far more likely to extrapolate.

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Robert Markette: which means they they do the audit of a sample.

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Robert Markette: And they say, Okay, well, in this sample, your error rate was X percent.

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Robert Markette: We’re then gonna take that percentage. We’re gonna go back. And then the sample cover a timeframe. Usually a year or 2,

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Robert Markette: we’re gonna look at the total amount of money Medicare paid you in that timeframe.

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Robert Markette: Multiply it by the error rate.

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Robert Markette: and that’s what they’re going to demand back. And so that can be. I had a case once about a $60,000 audit

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Robert Markette: that when they extrapolated became 2.4 million dollars.

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Dennis Gill: Oh, my God!

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Robert Markette: Which is crazy.

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Dennis Gill: Yeah.

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Robert Markette: And and the other thing they’ll do they can do is they can say, Hey, we’ve done this audit.

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Robert Markette: We think there’s problems we want to keep investing, and so we are going to suspend your Medicare payments.

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Dennis Gill: While we continue to investigate.

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Robert Markette: And and you have the right, if they do that, to submit a letter saying, Hey, guys, can you can you rethink this? It’s not a formal appeal. You don’t get to go to Alj. It’s just a letter that you can write asking for them to reconsider suspending your payments in my experience. They don’t, and then that means your payments will be suspended

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Robert Markette: while the investigation continues, and that can continue for 6 months, and they can extend it beyond that if they want. So when a you pick shows up, things can get a lot more painful.

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Dennis Gill: Definitely. It can’t. It can’t.

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Robert Markette: So those those are the kind of audits you could possibly be facing as a home care provider.

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Dennis Gill: Okay, okay? And what are the top compliance areas? Agencies should monitor regularly to stay audit ready, or particularly regarding Medicaid and hipaa.

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Robert Markette: So from a compliance perspective

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Robert Markette: on the audit side, there’s obviously several issues that are are big in terms of eligibility. You can actually get data. The the Max published data every quarter or so showing the top audit error rates

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Robert Markette: one that’s of interest from from a compliance standpoint is

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Robert Markette: at least for Palmetto’s data. A significant percentage of providers

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Robert Markette: have audit outcomes that are negative because they just didn’t respond. Palmetto. Last time I looked was looking at 40% of their auto requests just didn’t get a response. So one is

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Robert Markette: from from our perspective. When the letter comes in. When you get an Adr request. Do you have the components and pieces in place to respond?

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Robert Markette: Are you prepared

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Robert Markette: to get the documents together? We accepted, request an extension of the deadline and things like that to get the documents out the door.

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Robert Markette: So you at least get to get to the Second level, which is when they audit you, and and maybe you don’t lose everything. So that’s a big one, obviously, for for audits, for home health. It’s, you know, face to face is a big one. They look at homebound status

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Robert Markette: on on the Hospice side you get

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Robert Markette: term illness, eligibility. They’re always looking at eligibility, but it’s home. Health Hospice.

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Robert Markette: you know. You get the same thing with waiver, they can look at eligibility and just let sure the patient been there. But and does the documentation show the services provided.

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Robert Markette: Hipaa, the biggest thing you’re seeing there. So hip is more complaint driven, not been investigation driven.

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Robert Markette: So when you get a complaint, and and the government comes up the most common thing. You see agencies and and not just agencies, but providers across the board from hospital physician providers get cited, for in hipaa is

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Robert Markette: a failure to do a hipaa risk assessment. So one of the components of the security rule

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Robert Markette: is that you’ve performed a risk assessment to analyze. You know where are your weaknesses.

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Robert Markette: things you need to fix, and and that should be done on a recurring basis. A lot a lot of home health and hospital fighters and home care. We did that at the beginning, you know, back when Hipaa came online 15 years ago and haven’t revisited it.

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Robert Markette: Well, what we’re seeing now is when Ocr. Gets a complaint and comes out. One thing they asked to see is your risk assessment. If you haven’t done a recent risk assessment.

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Robert Markette: They’re really hammering folks, imposing fines and penalties for not doing that risk assessment, because what the office of civil rights thinks is, if you haven’t done the risk assessment.

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Robert Markette: You can’t possibly be in compliance

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Robert Markette: from hipaa standpoint. So that’s a big one with hipaa, obviously, also with Hipaa. You want to be, you know, cognizant of patient rights and making sure you’re granting patients access. If you’re a Home Health agency, remember the Medicare Home health cops

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Robert Markette: give you a much shorter window to respond requests for access.

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Robert Markette: Another one I’ve seen a lot of lately is, what do I do when a patient has passed

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Robert Markette: and relatives come looking for information, making sure that I’m dotting the i’s across the t’s properly to deal with Phi, because Hipaa still applies, even though they’re deceased. It just alters who can ask for the records

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Robert Markette: and then surveys. That’s an ongoing issue for us.

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Robert Markette: you know. You see, a lot of issues with the surveys coming out.

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Robert Markette: We have a lot of administrative issues, you know, are are the is the administrator maintaining control? Is the industry in control, or do we have related entities?

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Robert Markette: Are we meeting with our staff our staff things of that nature?

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Robert Markette: And then that gets into more just general patient care issues of how we’re documenting the care does our documentation show? Because one of those common things I see across the board in home care

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Robert Markette: is we get comfortable with our patients? We get to know them, we see them. And then what happens is we stop writing stuff down

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Robert Markette: because we know the patient. Oh, that’s Mrs. Smith.

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Robert Markette: The problem for that is, if you don’t write it down. It didn’t happen, and and you might know the patient, you might have a good relation with the patient. But what if you’re not there or heaven forbid! What if something happens to you? If you’re in the hospital, if you’ve not written something on the patient, how do we care for the patient? How do you know what’s going on with the patient? How do your colleagues fill in with the patient? And when the surveyors show up, or auditors or investigators.

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Robert Markette: They’re all gonna look at that. They’re not gonna give you the benefit of the doubt. They’re just gonna see gaps in the documentation, or they’re gonna see documentation where every visit looks the same.

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Robert Markette: So we got to be careful when we’re documenting that we’re writing down what happens that we’re writing it down as we’re documenting contemporanecy with the care and and we’re not.

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Robert Markette: you know, falling into that habit of.

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Robert Markette: because we know the patient. We’re comfortable with the patient. We’re just, you know, jotting down a couple of notes and moving on.

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Robert Markette: because that’s

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Robert Markette: we may know I’ve had the common audits where I go to the nurse, and like I don’t understand why this patient’s getting healthcare or home care what what is what’s going on here. Well, the nurse starts to all the stuff is going to patient. That wasn’t the file. And you’re like, well, we really need to write that down.

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Robert Markette: Yeah, no.

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Robert Markette: I’m asking questions because I’m your attorney. But the auditors aren’t gonna ask. The surveyors aren’t gonna ask. They’re just gonna assume you’ve done something wrong.

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Dennis Gill: Yeah, everything should be documented here that should be a record should be there.

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Dennis Gill: And how can agencies effectively develop and maintain documentation practices to meet audit standards and minimize potential liabilities. I think you discussed a little bit about that. Anything more we want to add on that.

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Robert Markette: Yeah, well, I think I think one obviously know the standard. So so

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Robert Markette: you’ve got Medicare and Medicaid Survey standards because they’re going to survey you to the cops, you know. Document to the cops. But then you’ve got your payer standards. And what do I? What do I have to document for eligibility. What is the document to support the codes I’m using? What am I documenting to support medical necessity.

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Robert Markette: you know, if a longer length of care patient. Why, why is this patient still getting care? Why have goals not been met? Maybe goals aren’t going to be met. Maybe this is going to be a long term custodial, patient. But then remind, I like to tell folks you gotta remind your staff

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Robert Markette: that documentation is not just about the agency.

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Robert Markette: It’s about

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Robert Markette: the individual price. So so a lot of our staff, we have nurses, we have therapists. They’re all licensed professionals.

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Dennis Gill: And if you go in every state I’ve looked at, if you look at the professional licensing standards.

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Robert Markette: They’ll speak to documentation and and you can. And I’ve actually done presentations at state associations. We’ve talked about the personal risk to licensed professionals about failing to document properly, or, you know, sometimes our staff get nothing to hammer on our staff. They get in a hurry, and and we’re trying to get stuff done

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Robert Markette: and they’re not. And this comes up a lot. I’ve seen this, you know, with Vmr. You go in there and it timestamps the entry, and you’re like, well, it’s interesting that Mr. Smith signed this note at 3 o’clock in the morning.

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Dennis Gill: I’m fairly certain you weren’t in there. Well, they were in the home. They’re taking notes on a sheet of paper, and then they go home to document because they’re trying to get through all their visits.

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Robert Markette: And I appreciate the workload. But that that’s a problem. If I’m documenting later.

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Robert Markette: maybe my documentation is still accurate. But then then you go back to Hipaa, and I don’t think the providers think about that notebook that you’re writing stuff down in a patient’s home to take home with you.

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Robert Markette: That’s full of hipaa. Did you dispose of that notebook properly? Did you shred it when you were done? Probably not. It’s probably got, you know. You put 5 pages, and it’s probably got your your grocery list in it. It’s got other stuff, all kinds of stuff. So

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Robert Markette: it’s really important to educate staff and to re-educate them, and and both on the standards, what we’re trying to, what we’re trying to document to what the records should look like, but also that for our licensed professionals.

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Robert Markette: This isn’t just about the agency. It’s about your personal professional license. You worked hard to get this license, and I’ve had cases where I’ve had surveyors make nursing complaints against nurses due to things that happened during a survey. So you want to be sure you’re documented because you might find you’re responding to a nursing board complaint or therapy board complaint because some surveyor

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Robert Markette: or audit or somebody else gets upset about something on the documentation, and I don’t. I don’t think our staff thinks about that. I think we need to remind them that they have a dog in this fight, and they need to be. There’s a personal risk for them that they need to thinking about.

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Dennis Gill: Definitely definitely, and that does cover most of the things about the next query that what proactive steps can agencies take to prepare staff for audits.

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Dennis Gill: And are there any specific trainings or protocols that you recommend for that.

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Robert Markette: Well, I like the I’d like to look at

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Robert Markette: like the documentation like like a classic example of home health.

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Robert Markette: You know, we’re documenting in a home health for Medicare. We got to show homebound status.

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Robert Markette: and the thing I see all the time is

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Robert Markette: leaving the home is severe and taxing. Effort like that has been the magic words for home health, you know, homebound status.

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Robert Markette: For as long as I’ve been doing this.

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Robert Markette: But if you actually go look in the Medicare benefit policy manual.

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Robert Markette: It’s it’s essentially a 3 part test. Now, severe and taxing effort is part of that essentially. But there’s other things need to be documented. So I think

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Robert Markette: you go to that

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Robert Markette: expert for the benefit benefit policy and you educate them. Hey? Don’t forget. These are the elements for

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Robert Markette: Hospice for terminal illness. There are Lcds and there are Lcds for home health go through. This is what the Mac has said. They, looking for. They’re looking for in the documentation. So let’s go over this. Let’s be sure we’re documenting to those standards.

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Robert Markette: Do audits right? And then when you find problems you can do. Insert, hey? We? We can do some audits.

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Robert Markette: And we notice these things are are lacking. We’re missing these details, or we’re noticing that

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Robert Markette: the notes are are fit in a pattern.

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Robert Markette: You see this in those emrs, or there’s check boxes and things like that where

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Robert Markette: the staff gets kind of like. I. I have a daughter who’s in her second year of nursing now, and I remember when she was doing clinical, she came home one day, and she was discussing this nurse she shadowed, who was copying and pasting. She copied the last entry and put in the next entry. Well, in this particular she she was in a hospital, setting. The patient according to the notes that she, the nurse, had copied, had had trach care.

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Robert Markette: but the patient’s trach had been removed 3 weeks ago, but the nurse just kept cutting and pasting, and so

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Robert Markette: right it’s it’s easy we’re in a hurry, we don’t. We’re not looking at. We’re cutting and pasting, and I told my daughter I said, Look, I I can’t emphasize to you enough.

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Dennis Gill: Don’t ever do that.

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Robert Markette: Yeah.

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Robert Markette: find out you’ve done that. You’re going to be in trouble with me, not nursing board. And so our staff, you know. There, there may be steps within the software. We can do to limit their ability to cut and paste and things like that. But we need to remind them, look. That’s not how we document, you know. So educate that. And when we have audits, when the audit findings come back, the auditors are going to tell you things you’ve done wrong.

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Robert Markette: Go back to the staff educate, and then you’re going to repeat the education like, I tell clients you can’t just tell your staff once.

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Robert Markette: So there’s some baseline stuff, you know. What’s it? What’s it mean to document homebound status? What’s it mean to document a visit property? What’s it mean to document, you know, medical necessity, all the things you need to write down. We’re going to go over that again and again, maybe we’re sending emails with reminders. Maybe it’s an in service.

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Robert Markette: You know, there’s other training components. You can get through various companies where you can do other types of online training.

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Robert Markette: I really think it’s important to train, train and train again, because the staff will forget, and then

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Robert Markette: that as we find gaps, we find problems as we identify things through surveys and audits that we then train on those gaps. We identify the problem. We fix the problem and we train on that to make sure. Hey? The survey identified. We did this wrong. Gotta fix it. Here’s how it’s just. It’s an ongoing process, because the other thing, too, is

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Robert Markette: standards will change guidance. We just got the new Home Health Survey guidance this year from Cm. And so that changes how we do things. And so we gotta go back and tell us that. Okay, we did it this way for the last 10 years. But now Cms wants it done this way. So this is how we’re gonna do it.

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Robert Markette: And then we we train train and train again. I just

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Robert Markette: training is, I think, an area that

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Robert Markette: we have so many things to train about.

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Robert Markette: And we sometimes overlook documentation. I think because you have a limited number of things you can trade out every year. But I do think when you really focus on that and make sure we’re hitting those key elements and reminding folks, especially avoiding shortcuts and things like that, because those things I see providers get in trouble for.

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Dennis Gill: Yeah. And lastly, in case of adverse audit findings, what options do agencies have for appealing, and how can they better position themselves for a successful appeal. Your point was on that.

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Robert Markette: So. And and this is something I’ve been. I’ve been doing a lot lately. The the home health and hospital audits have been on the uptick for several years. So step one right when you you have the audit.

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Robert Markette: What I tell clients usually that where we start in preparing for audit results. You get the the request for documents from the auditor. You submit those documents. We always keep a copy for ourselves. Then I recommend

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Robert Markette: at that point we bring in a 3rd party consulting company to audit the records as well

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Robert Markette: to find out. What are we looking at? Is it good? Is it bad? Often.

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Robert Markette: you know, the 3rd party auditor might actually grade you more harshly than the

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Robert Markette: the Mac or the Smirk, because what the what their auditors are going to do. They’ve got a huge caseload. They’re going to find the 1st thing they can find to disqualify the record.

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Robert Markette: that’s all they’re gonna look at. Okay, homebound status not supported face to face, documentation missing.

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Robert Markette: They’ll look at the rest, and then they’ll they’ll add that to the pile of okay bad claim.

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Robert Markette: But if we have, the the auditor comes in they look at it. We’ll have a report in advance. So we’ll look at. Here are our deficiencies. Here’s we need to argue. Here are potential defenses. We have the claims we can and can’t fight.

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Robert Markette: Then you get that. You get the demand letter.

00:17:55.250 –> 00:17:58.990
Robert Markette: Usually the auto. You get an audit result first, st like, if you get a U pick audit.

00:17:59.170 –> 00:18:10.649
Robert Markette: if you pick, send you a letter says, here’s we found that’s not technically your demand, you will get a demand from the Mac saying, Okay, you’ve been audited. Here are the claims that are in error. Here’s what you owe the government.

00:18:11.430 –> 00:18:13.070
Robert Markette: That’s when the clock starts.

00:18:13.430 –> 00:18:20.840
Robert Markette: and and now you’ve got, you know, a timeframe to get your po filed and the key there is. If you get the appeal filed quickly.

00:18:21.220 –> 00:18:26.289
Robert Markette: They won’t start recouping, and if you don’t appeal they’ll begin to recoup your dollars. And so what’ll happen there is.

00:18:26.380 –> 00:18:32.069
Robert Markette: they’ll basically hold a hundred percent of your reimbursement until the overpayment has been paid. You get the appeal filed

00:18:32.300 –> 00:18:35.630
Robert Markette: within 30 days of the letter.

00:18:35.710 –> 00:18:39.620
Dennis Gill: Though, that prevents recruitment at the 1st level. So you’ll prepare your response.

00:18:40.160 –> 00:18:47.349
Robert Markette: And you’ll submit it. You have longer than 30 days to submit it, and if you submit later than 30 days, the the recoupment might start.

00:18:47.600 –> 00:18:50.869
Robert Markette: but it should stop upon submission of your appeal.

00:18:51.270 –> 00:18:52.870
Dennis Gill: The best is before 30 days.

00:18:52.870 –> 00:18:59.470
Robert Markette: Yeah, do it. And and that’s where, having done the audit in advance, we’re already prepared. So we can move quickly to file the appeal because you’re

00:18:59.600 –> 00:19:03.460
Robert Markette: it would be shocking to me if you get audited. They don’t come back and demand money.

00:19:03.510 –> 00:19:09.610
Robert Markette: Now you might get a load. I’ve had a couple of clients that demand comes back, and the numbers are so small that you know what. Let’s just pay it

00:19:09.800 –> 00:19:14.570
Robert Markette: because there, there’s a cost benefit. Right if you come back, and they’re demanding $800,000.

00:19:14.710 –> 00:19:20.059
Robert Markette: All of a sudden the cost of litigating makes sense. If they’re demanding 5 or 10.

00:19:20.650 –> 00:19:29.219
Robert Markette: That’s the point. Right? Well, by the time it goes, all the effort, the appeals, because you’re gonna have to get to the 3rd level before you really see any any success. Because the the 1st 2 levels.

00:19:29.330 –> 00:19:37.870
Robert Markette: the reconsideration, you’re basically going back to the same folks that audit you and say, Hey, guys, come on we tried, can we? Can we think about this?

00:19:37.970 –> 00:19:43.550
Robert Markette: Not surprisingly. You don’t like. I’ve I’ve had several appeals in the last year.

00:19:43.580 –> 00:19:47.450
Robert Markette: and I was just talking to the the consult, the consultant on the appeals.

00:19:48.100 –> 00:19:55.930
Robert Markette: trying to recall if any of the claims we appealed got reversed before we got to the Alj, and I think there was one.

00:19:56.180 –> 00:19:58.209
Robert Markette: and that was one where the the

00:19:58.220 –> 00:20:06.519
Robert Markette: the intermediate, the quick, which is the second Level appeal, reversed it before we even appeal. They’re like, Oh, wait! Hold on! And they they dumped it. But otherwise

00:20:06.800 –> 00:20:14.950
Robert Markette: you gotta use the 3rd level, which is the Alj, and and that’s important just to want to set expectations that don’t. Don’t be surprised if you are appealing. You lose the 1st 2 levels

00:20:15.340 –> 00:20:27.340
Robert Markette: when you get by the time you get to the 3rd Level, the recruitment will start. The recruitment only lasts through the 1st 2 levels to get to the Lj, they’re going to start taking your money, and in some cases you may have already had all the money taken before you get to the Lj.

00:20:27.780 –> 00:20:29.440
Robert Markette: But at the Alj level

00:20:30.100 –> 00:20:36.629
Robert Markette: now you have an independent 3rd party administrative law judge the office of Medicaid hearings and appeals. Who’s going to look at that claim?

00:20:37.160 –> 00:20:38.040
Robert Markette: And

00:20:38.320 –> 00:20:45.180
Robert Markette: at that level providers are are much more likely, like a 50 or 60% success rate at that level.

00:20:45.290 –> 00:20:47.990
Robert Markette: But it’s important to get to that level

00:20:48.070 –> 00:21:04.629
Robert Markette: that at the 1st 2 levels. You’ve made a clear record. So one of the I recommend getting an attorney involved at the beginning, even if maybe you file the appeal yourself, because one thing that’s very important at 1st Level is to make sure you submit all the evidence. And so what I will do

00:21:04.670 –> 00:21:07.109
Robert Markette: at the 1st note I submit the entire medical record.

00:21:07.390 –> 00:21:17.040
Robert Markette: even if it’s not completely relevant, because that way it’s all available later to argue with the Alj. I had a case once where the client handled the appeal.

00:21:17.090 –> 00:21:22.139
Robert Markette: and they misunderstood the issue in the appeal, and they only submitted a handful of documents for each client.

00:21:22.450 –> 00:21:33.179
Robert Markette: and when I got involved in Alj level. The problem we had was that the documents they submitted did not respond to the specific issues of the auditor in the original denials. They weren’t. They weren’t helpful.

00:21:33.410 –> 00:21:38.990
Robert Markette: So at the Alj level you can add evidence. But you have to show good cause.

00:21:39.260 –> 00:21:43.510
Robert Markette: So we filed a petition and explained our good cause for wiresort evidence.

00:21:43.670 –> 00:21:46.809
Robert Markette: Well, not surprisingly. Ljs have a large caseload.

00:21:46.990 –> 00:21:53.090
Robert Markette: and the Alj. Sees a way to close out a case quickly, because if I’m coming to Lj. Saying like, I need this evidence to win

00:21:53.396 –> 00:22:00.549
Robert Markette: is like, Wait. If I don’t let them add the evidence. This case is over. I can close this file and move on to my next one, because they have lots of files.

00:22:00.790 –> 00:22:01.279
Dennis Gill: Got it.

00:22:01.280 –> 00:22:08.059
Robert Markette: And so, not surprisingly, Lj, didn’t let us add evidence which meant we could not address the specific deficiencies

00:22:08.150 –> 00:22:15.660
Robert Markette: that the that was a basis of the appeals because we didn’t have the documents in the record because we had, they had not been submitted the 1st Level. So it’s very important that 1st level

00:22:15.750 –> 00:22:27.760
Robert Markette: you get all the documentation, because when you get to the Alj you can’t add documentation, it’s it’s a de noble review. The Alj will review everything de novo, which means it’s a clean slate. The the Alj doesn’t care

00:22:27.790 –> 00:22:33.149
Robert Markette: what the quick ruled or the lower level. The Alj makes their own determination.

00:22:33.180 –> 00:22:38.399
Robert Markette: but you have to have the records in evidence for them to make that determination. So let’s say

00:22:39.020 –> 00:22:44.470
Robert Markette: your case was, your claim was denied for deficient or missing face to face, and let’s say you had it.

00:22:44.560 –> 00:22:52.170
Robert Markette: but you forgot to submit it when you get to Alj level. If that face to face isn’t there, and the Alj. Doesn’t find you have good cause to submit it.

00:22:52.230 –> 00:23:00.199
Robert Markette: It doesn’t matter. You had it. It’s not in the record, so you’ll still lose that claim, even though you actually have the face to face because you didn’t submit it at the 1st level.

00:23:00.220 –> 00:23:15.310
Robert Markette: So it’s when you get that demand. It’s worth reaching out to an attorney who understand. I’m not saying this to create work for myself or other attorneys, but it is a good idea to talk to an attorney about the process and getting them involved. Even if, again, if you think you can write the initial

00:23:16.120 –> 00:23:17.859
Robert Markette: 2 levels of appeal yourself.

00:23:17.870 –> 00:23:20.150
Dennis Gill: Make sure that you’re getting guidance.

00:23:20.400 –> 00:23:21.400
Robert Markette: To

00:23:21.900 –> 00:23:36.660
Robert Markette: make sure you have all the right evidence in place, and and I’ve I’ve got a couple of consultants I work with where it’s not cost effective for me to get involved to get to the Lj. But I’ll look at and say, Well, here’s some arguments to raise, and and the consultant will just add those into the boilerplate letter. They submit.

00:23:36.940 –> 00:23:44.990
Robert Markette: Make sure they’ve got all the evidence, you know. It’s like, here’s the here’s the record we should have. Then they do the rest, and then we then I know when I come into the Lj level

00:23:45.000 –> 00:23:53.599
Robert Markette: I know what was submitted the 1st level. I know we submit the entire medical record for the patient. So I have all the evidence I need to make. Whatever arguments I want to make with the Alj.

00:23:53.890 –> 00:24:01.670
Robert Markette: As opposed to showing up later like, Oh, wait! We missed this document or that document, and the judge will enter it. So that’s very important to talk, to counsel

00:24:02.250 –> 00:24:06.169
Robert Markette: early on, to make sure that you have those records, because if you don’t.

00:24:06.920 –> 00:24:14.249
Robert Markette: then you’ll be able to make a claim. And the other thing, too, is to make sure that when you get the demand you calendar your deadlines, because if you miss a filing deadline.

00:24:14.260 –> 00:24:15.970
Robert Markette: either on at any level

00:24:16.050 –> 00:24:22.990
Robert Markette: if you’re late. The appeals over, and there’s nothing you can do about. So I’ve I’ve had clients where they’ve reached out to say, Hey, we need help with this appeal

00:24:23.490 –> 00:24:25.220
Robert Markette: like, sure. Send me the documents.

00:24:25.430 –> 00:24:30.140
Robert Markette: and so I send the demand letter over. I look at it. I’m like you guys got this 6 months ago.

00:24:30.160 –> 00:24:40.869
Robert Markette: like, well, yeah, we were. We were talking to the Mac, you know, about the appeal. And and you know, maybe we could work some of this out and and and there’s an option in the letter. It’ll tell you you there’s a dispute resolution process.

00:24:41.060 –> 00:24:52.850
Robert Markette: And so they had talked to the Mac, and not surprisingly, the Mac kept talking to them. And then so you know the appeal deadline like 180 days on day 1 81, the Max like, well.

00:24:53.220 –> 00:24:55.970
Robert Markette: we’re not going to talk anymore. We we want to keep the money.

00:24:56.050 –> 00:25:06.160
Robert Markette: Well, at that point you’re they. They knew what they were running the clock out right. It’s like watching a football game. They’re the clocks ticking down like we just gotta get to the end of the got got to get the final whistle.

00:25:06.580 –> 00:25:18.010
Robert Markette: and so they came to me and I said, I can’t help you, I said, we. This appeal needs to be filed 2 days ago, and and there’s nothing I can do to resurrect it. It’s it’s an absolute bar to the claim. So you gotta be very careful to understand.

00:25:18.190 –> 00:25:19.230
Robert Markette: If you

00:25:19.360 –> 00:25:31.710
Robert Markette: get that demand letter, there’s an appeal deadline. If you don’t formally file appeal. Talking to the Mac, if you don’t formally file the appeal for the pro procedure outlined in the letter. Then you will. You will no longer have a right to appeal.

00:25:32.060 –> 00:25:35.899
Robert Markette: and the likelihood of getting that overturned later is very low.

00:25:35.910 –> 00:25:43.699
Robert Markette: It’s an absolute bar of the claim. So I always tell clients you’ve got to be very aware of those deadlines, and be sure you don’t miss them.

00:25:43.800 –> 00:25:46.550
Robert Markette: cause when you call me the day after the deadline passed. I’m like

00:25:47.060 –> 00:25:53.219
Robert Markette: It’s a sad story. I appreciate your frustration, but I don’t have a time machine, and so I can’t help you.

00:25:53.630 –> 00:25:54.170
Dennis Gill: Got it.

00:25:54.170 –> 00:25:59.530
Robert Markette: That’s really important. When you have your documents, don’t miss your deadlines. That’s the 2 biggest things of those appeals.

00:25:59.530 –> 00:26:01.441
Dennis Gill: Yeah. So timeline is pretty important.

00:26:02.452 –> 00:26:09.640
Dennis Gill: Okay, okay, okay, all right. So thank you. Thanks a lot, Robert, for sharing your expertise today.

00:26:09.760 –> 00:26:17.300
Dennis Gill: And to our lovely audience. Thank you for tuning in until next time. I’m Dennis Gill, signing off.

00:26:17.410 –> 00:26:18.900
Dennis Gill: Have a good one. Everybody.