Attorney Knicole Emanuel has posted another incredibly important article detailing the story of a wound care practitioner’s journey with a Medicare audit all the way to the level of an Administrative Law Judge (ALJ) hearing. Her client was a mobile wound care practice treating severe pressure ulcers with amniotic “skin substitutes.” Her client was audited over 3 patients treated in 2024.
Medicare Part A and B appeals have five levels:
- Redetermination by the Medicare Administrative Contractor (MAC)
- Reconsideration by a Qualified Independent Contractor (QIC)
- An ALJ hearing
- Medicare Appeals Council review
- …and finally, federal district court
As Knicole notes, providers widely regard the first two levels as “rubber stamp denials.” The ALJ hearing is the first time an independent adjudicator, not a contractor paid to administer the program, actually weighs the full record and hears testimony.
You need to read her entire blog but pay close attention to the big mistake that the practice made at the very beginning of the process. When the clinic received the audit request from the Unified Program Integrity Contractor (UPIC), it hired an outside consultant to pull the records. The consultant did not pull all the documentation which would have justified that the requirements for conservative care had been met prior to the skin sub applications, and the contractors denied the claims.
Ordinarily, a provider cannot introduce new evidence at the ALJ level unless the judge finds good cause for the late submission (42 C.F.R. §§ 405.1018 and 405.1028). Knicole argued that since the additional records were written contemporaneously and were left out because of a vendor’s incomplete production, they should be admitted and the ALJ allowed it. That was a significant win, but it should not have been necessary.
Clinicians need to produce the complete record the first time. Know where all your documentation lives. If you have a wound-care-specific EHR but are keeping some of the documentation in the hospital EHR (e.g., labs and studies), then make sure that those records are produced.
She also points out something that I have heard repeatedly which is that the contractor does not send anyone to the ALJ hearing to defend the reasoning behind their denial. This raises some real “due process” concerns because unlike in civil litigation, they are not required to show up and submit to cross examination.
Knicole proposes some modest reforms that would make a real difference including allowing the ALJ to give reduced weight to findings the contractor declines to defend.
Read Knicole Emanuel’s full post, “Inside a Medicare ALJ Hearing: A Wound Care Appeal, a Hard-Won Evidentiary Ruling, and an Empty Chair” (November 4, 2026).
Related Posts:
- Medicare Skin Substitute Audits: “Agencies Cannot Make Up the Rules” – Guest Blog by Michael Crouch – Caroline Fife M.D.
- The Incredible Journey: Lessons Learned from a “Skin Substitute Graft” Audit – Part One
- Here Comes the Judge! Part 2 of the Incredible Journey of a Skin Substitute Audit – Guest Blog by Michael Crouch
- The Incredible Journey: Lessons Learned from a Skin Substitute Graft Audit (Part Three) – Caroline Fife M.D.
- More Details About Audit Requirements: Guest Blog from Michael Crouch – Caroline Fife M.D.
- Check Out Attorney Knicole Emanuel’s Post About Escalating Medicare Provider Audits to Federal District Court – Caroline Fife M.D.
- Medicare Auditors Are Not Wound Care Specialists: Why Providers Win Appeals When the Full Story Finally Gets Read – Blog Post by Knicole Emanuel – Caroline Fife M.D.
- Medicare Auditors Can Use the 3 Active LCDs for Cellular Tissue Product (CTP) Audits in ANY State – Caroline Fife M.D.
- What do Successful Medicare Appeals Have in Common? (Knicole Emanuel’s Recent Blog) – Caroline Fife M.D.
Dr. Fife is a world renowned wound care physician dedicated to improving patient outcomes through quality driven care. Please visit my blog at CarolineFifeMD.com and my Youtube channel at https://www.youtube.com/c/carolinefifemd/videos
The opinions, comments, and content expressed or implied in my statements are solely my own and do not necessarily reflect the position or views of Intellicure or any of the boards on which I serve.
