PSC Audits | PSC Appeals | Medicare Fraud Support

The Provider's #1 Resource - Medicare PSC Audits & PSC Appeals
Medicare PSC Appeals & Legal Services / PSC Clinical & Compliance Reviews / Medicare Fraud & Abuse
Contact Us For Immediate Assistance - (303) 586-5003 or support@pscaudits.com

PSC Audits & Appeals Legal Services

Castle Rock Medical Group
Medicare Program Safeguard Contractor Consulting & Legal Services
Helping Providers Insure CMS Compliance & Benefits Integrity

PSC Audit Legal Services

Castle Rock Medical Group (a Jackson Davis HealthCare company) is the nation's undisputed leader in documenting, applying and implementing CMS clinical payment criteria, implementing Medicare clinical compliance initiatives and completing Medicare PSC audit clinical & documentation assessments. In addition, CRMG's Medicare consultants and clinical auditors have strong working relationships with the nations leading health law firms and Medicare PSC appeals attorneys.

Success in the PSC appeals process is centered on meeting CMS payment criteria, Conditions of Participation documentation requirements and Medicare evidence-based coverage policies - not on outdated legal arguments of subjective medical necessity. Focusing on individual patient clinical profiles, submitting required CMS supporting documentation and proving adherence to CMS payment criteria for each case is the only way to win PSC audit appeals.

PSC Appeals & Legal Services Profile

CRMG provides the nation's leading solution for the submission of Medicare PSC audit appeals. CRMG's industry-leading Medicare consultants and clinical auditors work directly with the nation's best health law firms and provide an unmatched consulting and legal services solution.

See the Medicare PSC Appeals section for a detailed overview of CRMG's PSC appeals support process:

                Step 1 - CMS Criteria-Based Case Review
                Step 2 - Prepare PSC Appeals & Criteria-Based Case Summary
                Step 3 - Submit Required Documentation for PSC Appeals
                Step 4 - Coordinate with Legal Counsel
                Step 5 - Provide Regulatory & Clinical Expert Testimony

To speak directly with one of our experienced Medicare consultants, clinical auditors or Medicare laywers - or for questions regarding Medicare PSC audits, Medicare PSC appeals, CMS billing and clinical criteria, PSC clinical audit assessments or other Medicare compliance related issues - please contact us directly at (303) 586-5003 or support@pscaudits.com.

Turning the Page - A Winning PSC Appeals Strategy

With the Medicare PSC audit program being initiated nationwide, providers are preparing for PSC audit denials and setting in motion a series of processes to successfully address PSC appeals. Hospitals, physicians, physical therapists and a full range of other healthcare providers are quickly and aggressively turning their focus to fighting & winning PSC appeals. Defending PSC auditor denials, avoiding potential fraud allegations and holding on to hard earned cash reserves are all foremost objectives.

Based upon our work with providers facing CMS audits (ZPIC audits, PSC audits, RAC audits and MIC audits), the 4 most frequently asked questions are (1) how do we keep our money and not pay a PSC's extrapolated amount, (2) how do we stop PSC audit denials in the future, (2) how do we win current PSC appeals, and (3) how do we stop PSC audit outcomes from turning into 'fraud' allegations.

Within the PSC Audit Appeals we address a wide range of issues and strategies to consider when initiating the PSC appeals process. Most importantly, however, we simply can't emphasize enough the challenges to winning PSC appeals and the very real possibility of PSC audit outcomes becoming potential Medicare fraud issues. Here are a handful of things to consider when tackling PSC appeals:

1) CMS Payment Criteria will give you the winning hand

Several U.S. courts have held that a provider's adherence to CMS payment criteria trumps all in the evaluation of claim denials. In fact, the courts have held that - when CMS payment criteria exists for a given focus area - CMS MUST use the payment criteria when evaluating claims for payment;

2) Develop CMS Criteria-Based Case Summaries for all "winnable" PSC appeals

Nothing speaks louder in the PSC appeals process than providers that painstakingly tie CMS payment criteria to medical records documentation and present an evidence-based argument for payment. On the other hand, using the "appeal everything" strategy and not making internal operational changes to adhere to CMS payment criteria is a guaranteed approach to facilitating potential Medicare fraud investigations;

3) Submit all required documentation during the first 2 stages of the PSC appeals process

It is critical that you file all the supporting documentation relating to a given case no later than Stage II - Reconsideration. After this stage, it is extremely difficult to add supporting documentation to a case under appeal. When completing CMS appeals and "mock audits" with providers across-the-country, we have found a number of hybrid medical record structures and significant challenges to submitting medical record documentation for review;

4) Focus on winning in the end

Remember, the Medicare Appeals Council is the last administrative step in the PSC appeals process. The Appeals Council relies heavily on CMS payment criteria in making decisions and their approach has shown time-and-time again that "legal or procedural" arguments are extremely difficult to win.

CMS / Medicare PSC Appeals Resources

The PSC appeals process mirrors other Medicare appeals, but the presence of extrapolated outcomes - as well as Medicare fraud implications - can make PSC appeals somewhat more challenging. Please see the Medicare PSC Appeals section for further information and guidance relating to recommended appeals work plan components. The following are CMS ZPIC appeals documents highlighted on the cms.hhs.gov website:

                        PSC Appeals - The Medicare Appeals Brochure
                        PSC Appeals - Appeals Process Diagram
                        PSC Appeals - Limitation on Recoupment

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Recommended PSC Appeals Law Firms

The PSC appeals process can be extremely costly and the timeliness of CMS recoupment is a major challenge. In addition, the ever-present issues relating to Medicare fraud can be very serious.

Knowledgeable, independent health law firms and internal legal counsel representatives play vital roles in the completion of proactive PSC medical review assessments & the submission of PSC audit appeals. In addition, CRMG's Medicare consultants, clinical auditors and legal support professionals emphasize a multi-disciplinary approach to addressing CMS appeals. We can assist in providing a full range of PSC appeals submission efforts as well as providing expert testimony, clarifying regulatory requirements and contributing to extensive research efforts.

Castle Rock Medical Group has researched hundreds of health law firms nationwide and we recommending only the very best. Our recommended health law firms and attorneys have hundreds of years of experience, they have assisted with over 10,000 Medicare appeals, PSC appeals and highly sensitive Medicare fraud related issues. This very select group of attorneys and firms that can bring both a breadth of experience with the Medicare appeals process and a depth of PSC audit appeals knowledge to each client - without the additional cost.

To speak directly with one of our experienced Medicare consultants, clinical auditors or Medicare lawyers - of for questions regarding Medicare PSC audits, Medicare PSC Appeals, PSC medical review assessments or other Medicare compliance issues - please contact us directly at (303) 586-5003 or support@pscaudits.com.

PSC Appeals Support - Recommended Medicare Lawyers

Mr. Buzz Cleveland
Crawford & Cleveland, P.C.
Denver, Colorado
(303) 228-1622
www.health-care-lawyer-denver.com

Mr. Greg Piche
Holland & Hart LLP
Denver, Colorado
(303) 295-8014
www.hollandhart.com

Mr. Robert Benvenuti
Barnett, Benvenuti & Butler PLLC
Lexington, Kentucky
(859) 226-0312
www.kyhealthlaw.com

Mr. Mike Cronan
Stites & Harbison PLLC
Louisville, Kentucky
(502) 681-0430
www.stites.com

Mr. Paul Kim
Ober|Kaler
Baltimore, Maryland
(410) 347-7344
www.ober.com

Mr. Ross D'Emanuele
Dorsey & Whitney LLP
Minneapolis, Minnesota
(612) 343-2161
www.dorsey.com

Mr. Ernie Tsoules
Tsoules, Sweeney, Martin & Orr LLC
Exton, Pennsylvania
(610) 423-4200
www.tshealthlaw.com

Ms. Carla Cox
Jackson Walker L.L.P.
Austin, Texas
(512) 236-2040
www.jw.com

Ms. Lisa Thompson
Fulbright & Jaworski
Washington, D.C.
(202) 662-0398
www.fulbright.com
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Other Leading Health Law Firms & Medicare Lawyers

Mr. Jon Cohn
Arent Fox, LLP
Los Angeles, California
(213) 443-7515
www.arentfox.com

Mr. Lloyd Bookman / Ms. Jodi Berlin
Hooper, Lundy & Bookman
Los Angeles, California
(310) 551-8111
www.health-law.com

Mr. Kevin Peters
Miles & Peters
Denver, Colorado
(303) 892-9900
www.mphealthlaw.com

Ms. Renee Jordan
Bacen & Jordan, P.A.
Ft. Lauderdale, Florida
(954) 961-5544
rjordan@bacenjordan.com

Mr. Barry Herrin
Smith Moore Leatherwood LLP
Atlanta, Georgia
(404) 962-1027
www.smithmoorelaw.com

Mr. Charles MacKelvie
Miller, Canfield, Paddock and Stone, P.L.C.
Chicago, Illinois
(312) 460-4234
www.millercanfield.com

Mr. Tom Neal
Krieg DeVault, LLP
Carmel, Indiana
(317) 238-6221
www.kriegdevault.com

Mr. Mike Grubbs
Barnes & Thornburg LLP
Indianapolis, Indiana
(317) 231-7224
www.btlaw.com

Mr. Steve Adams
Husch Blackwell Sanders LLP
Clayton, Missouri
(314) 480-1500
www.huschblackwell.com

Mr. Stewart Kirkpatrick
Crowley, Haughey, Hanson, Toole & Dietrich
Billings, Montana
(406) 252-3441
www.crowleylaw.com

Mr. Tom Stukes
Womble Carlyle Sandridge & Rice, PLLC
Greensboro, North Carolina
(336) 574-8065
www.wcsr.com

Mr. Tom Boyle
Buchanan, Ingersoll & Rooney PC
Pittsburgh, Pennsylvania
(412) 562-8800
www.bipc.com

Ms. Emily Towey
Hancock, Daniel, Johnson & Nagle, P.C.
Glen Allen, Virginia
(804) 967-9604
www.hdjn.com

Mr. Nathan Brown
Ropes & Gray
Washington, D.C.
(202) 508-4763
www.ropesgray.com

Mr. Jim Fredman
Foster Pepper PLLC
Seattle, Washington
(206) 447-2909
www.foster.com

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