ALJ wait time increases

OMHA, C2C pick away at backlog, but still no ‘broad relief’
Friday, May 27, 2016

WASHINGTON – The wait time for an Administrative Law Judge hearing keeps growing—a symptom of ongoing problems with the audit process, say industry attorneys.

“I don’t think the problem lies in appeals,” said Ross Burris, an attorney in the Atlanta office of Polsinelli. “The problem lies lower down, either with audits that are too broad, or MACs that are just rubberstamping what the audit contractors are doing.”

In the first quarter of 2016, the wait was 796 days. By the second quarter, it was 861 days—a 30% increase over the same period last year, when the wait was 661 days, according to a recent update from AAHomecare.

The Office of Medicare Hearings and Appeals has taken some steps to reduce the backlog. A settlement conference pilot project brings the provider and CMS together with a facilitator to try and work out a settlement.Although the pilot was tweaked in October, the bar—such as having a minimum of 20 claims or $10,000 at issue—remains too high for most HME providers, say stakeholders.

“I think OMHA is doing everything it can,” said Burris. “I think they have tried to increase the number of judges hearing appeals, and I think they’ve tired to come up within solutions within their small realm of power.”

Another demonstration project, launched early this year by C2C Innovative Solutions, the Qualified Independent Contractor for the second level of appeals, allows HME providers to discuss denials over the phone before a decision is made.

“These are steps in the right direction, but there’s so many suppliers and so many claims that have been audited,” said Stephanie Morgan Greene, chief consulting officer & general counsel for Acu-Serve. “You just don’t feel a broad sense of relief across the board.”

While long wait times have not deterred most providers from appealing claims to the ALJ, they have forced them to take a harder look at the reasons for denials.

“There have been so many denials for technical reasons that people want to go to the ALJ,” said Greene. “But they are also looking at what they need to fix, what trends they are seeing in denials, and truly attempting to fix things from the front-end processes.”