HAT Attorneys Philip Chapman and Julie Mitchell Obtain Fully Favorable Decision in $4.6M Medicare Appeal

HAT attorneys Philip Chapman and Julie Mitchell secured a fully favorable, $4.6 million Medicare appeal decision from United States administrative law Judge Michael J. Cianci, Jr. in favor of a long-time client on Jan. 5, 2022.

This case involved an initial determination from the secretary of the U.S. Department of Health & Human Services (HHS) that a family practice clinic, represented by HAT, was overpaid for urine drug screenings and other assorted lab tests provided between Jan. 1, 2011 and May 29, 2014 to Medicare beneficiaries receiving regular opioid prescriptions for pain management.

The clinic was audited by a Medicare Zone Program Integrity Contractor (ZPIC, which is now known as the Unified Program Integrity Contractor or UPIC) in 2014. The ZPIC initially found an alleged overpayment of $19,561.63, which was extrapolated across all of the clinic’s claims to a total demand for reimbursement of $4,655,794.47. Chapman and Mitchell appealed the individual denials of the claims reviewed, as well as the appropriateness of the sampling and extrapolation performed by ZPIC through the Medicare appeals process all the way up to federal court.

Once in federal court, Chapman and Mitchell introduced new evidence reflecting the current understanding of the nation’s opioid crisis. On Sept. 11, 2020, Judge Keith Starrett issued an order remanding the case back to the secretary for reconsideration of its final determination in light of this new evidence. Upon consideration of this new evidence, along with additional testimony provided by HAT’s statistical expert, Judge Cianci overturned the secretary’s findings in full, ruling that all appealed claims were for services which were reasonable and medically necessary and that the statistical sampling and extrapolation methodology was invalid and, therefore, overturned.

As a result, HAT’s client was found to be entitled to coverage for all claims at issue and qualifies for reimbursement of all sums previously recouped by HHS – plus interest.

To read Judge Cianci’s full decision, click here.