Payment Matters: RACs Unleashed: 9th Circuit's Palomar Decision Gives Even More Discretion to Medicare Contractors

Explore:  Audits Medicare

In Palomar v. Sebelius, D.C. No. 3:09-cv-00605-BEN-NLS (Sept. 11, 2012), the United States Court of Appeals for the Ninth Circuit held that a decision by a Recovery Audit Contractor (RAC) to reopen a Medicare claim for complex review was not reviewable. Providers already confronting a variety of challenges served up by Medicare contractors, will unfortunately find that the Palomar decision offers fresh cause for concern.

The Palomar case concerned a RAC's determination that services provided to a Medicare beneficiary were not reasonable and necessary. The claim in question was more than one year old, and so could only be reopened for "good cause" under Medicare regulations. All of the reviewing bodies that examined the case concurred with the RAC's determination regarding medical necessity. However, the administrative law judge (ALJ) who reviewed the RAC determination concluded that there was not good cause to reopen the claim, and therefore reversed the RAC. On appeal, the Medicare Appeals Council (MAC) reversed the ALJ and ruled that the Medicare regulation at 42 C.F.R. § 405.980(a)(5) makes a Medicare contractor's decision to reopen a claim unreviewable.

Please see full alert below for more information.

LOADING PDF: If there are any problems, click here to download the file.

Written by:

Published In:

DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

© Ober|Kaler | Attorney Advertising

Don't miss a thing! Build a custom news brief:

Read fresh new writing on compliance, cybersecurity, Dodd-Frank, whistleblowers, social media, hiring & firing, patent reform, the NLRB, Obamacare, the SEC…

…or whatever matters the most to you. Follow authors, firms, and topics on JD Supra.

Create your news brief now - it's free and easy »

All the intelligence you need, in one easy email:

Great! Your first step to building an email digest of JD Supra authors and topics. Log in with LinkedIn so we can start sending your digest...

Sign up for your custom alerts now, using LinkedIn ›

* With LinkedIn, you don't need to create a separate login to manage your free JD Supra account, and we can make suggestions based on your needs and interests. We will not post anything on LinkedIn in your name.