Court Upholds Medicare Contractor’s Decision to Deny Claims Based on Untimely Appeal

A Court has ruled that Palmetto GBA, a Medicare contractor, acted correctly when it denied a provider’s untimely appeal [Five Points Healthcare of NC, LLC v. Becerra, No. 7:22-CV-81-D (E.D.N.C. Apr.13, 2023)].The Court decided that it did not have subject matter jurisdiction because dismissals of two requests for reconsiderations were not final determinations and, therefore, were not subject to judicial review. The Court also said that even if the denials were final determinations, the provider’s claims would fail on their merits.

Five Points Healthcare of NC, LLC; d/b/a Native Angels Homecare Agency, Inc.; was certified by the Medicare Program to provide home health services. The Agency was subject to an audit by the Zone Program Integrity Contractor (ZPIC).

The Agency claimed that the ZPIC failed to send appeal documents to Palmetto on a timely basis. The Agency’s claims were, therefore, denied. The Agency then asked Palmetto to reconsider the denials based on the actions of the ZPIC, but the Agency did not file its request for reconsideration until more than sixty days after the claims were denied.