Judge Offers Final Ruling in CMN Case

REDDING, Calif.–After eight months of waiting, HME owner Tom
Lambert of Maximum Comfort–who won a favorable preliminary ruling
last year in a suit contending a CMN is sufficient proof for
supplier reimbursement–received a final ruling March 7.

In this ruling, Judge Lawrence Karlton of the Eastern District
of California stated again that “the plain language of [the law]
provides that any medical necessity information required from
medical equipment suppliers may be submitted to the Secretary only
by way of a Certificate of Medical Necessity, and not by other
means, such as obtaining Medicare beneficiaries’ medical
records.”

The case began when Lambert appealed, then filed suit against, a
Medicare decision that the government overpaid Maximum Comfort
because of inadequate documentation for power chair claims. The
preliminary ruling, issued last June, was in Maximum Comfort’s
favor. Lambert was instructed to make a request to get back the
money Medicare had recouped during claims appeal–an amount he
determined at $425,000 in principal and interest.

But in his recent ruling, Judge Karlton said the court does not
have the power to tell the government how much it owes Maximum
Comfort. Due to legal precedent, he wrote, a district court “must
now remand the case to the Secretary for a final determination on
the calculation of the underpayment amount due to [Maximum
Comfort].”

In other words, Lambert’s fate once again rests with the
government, which will determine how much money he will get
back.

Since the district court ruling is now final on the matter of a
CMN’s sufficiency for claims reimbursement, the government has 60
days from March 7 to file an appeal, Lambert said. “The U.S.
attorney said they were going to,” he added, “but who knows now? If
they appeal it and lose, they take a risk of making [the ruling]
national policy rather than just in the Eastern District of
California.”

For more on the Maximum Comfort case, visit the July 12, 2004,
HomeCare Monday by clicking
here, and the July 19, 2004, edition by clicking
here.