HHS Appeals Maximum Comfort Case

San Francisco

The government is appealing a federal judge’s ruling that a properly completed certificate of medical necessity is proof enough for provider reimbursement.

“The ball’s in their court now,” said Maximum Comfort President Tom Lambert, who filed a lawsuit against the Department of Health and Human Services several years ago after Medicare said it had overpaid his company because of inadequate documentation for power wheelchair claims from 1998 to 1999.

In March, Lambert received a final favorable ruling from a U.S. District judge, who stated that a DME supplier should not be required to submit additional medical records beyond a CMN.

HHS Attorney Ana Maria Martel filed the appeal May 4, and the case now moves to the 9th U.S. Circuit Court of Appeals in San Francisco, where it is expected to be argued in January. Martel declined further comment.

Ironically, since receiving a preliminary ruling in his favor last year, Lambert has downsized his Medicare revenue and now sends 60 percent of his business to Medi-Cal, the state’s Medicaid program.

“You may have to submit different paperwork three, four or five times, but in the end [Medi-Cal] pays you, and they don’t take the money back and conduct a post-payment audit two years later,” Lambert said.