Appeals backlog forces providers to reassess biz practices

YARMOUTH, Maine - Forty-three percent of respondents to a recent HME NewsPoll say they're filing fewer appeals due to the massive backlog at the ALJ level.

Of those filing fewer appeals, the majority say they're now handling denied claims by either asking patients to sign ABNs and pay out of pocket (30%), or picking up their equipment (26%).

“I very carefully review the documentation and situation to determine whether to appeal, pick up the equipment, 're-qualify' the patient and start over, or cut our losses,” wrote Sharon Suchomel, DME billing and compliance for ThedaCare At Home in Appleton, Wis. “Many factors go into this, such as patient circumstance, technical vs. not meeting medical necessary denial, cost of equipment, etc. It depends on whether it is worth the time and effort to advocate for the patient or try to 'win'/prove a point to Medicare.”

The Office of Medicare Hearings and Appeals recently reported that during the first quarter of 2015 alone, 128,000 appeals were filed at the ALJ level with an average processing time of 588.9 days.

Respondents say they're trying their hardest to make appeals unnecessary by doing more on the front end to get claims paid, but this comes at an increased cost.

“As with all providers, we're struggling with the minutiae (date stamps, signature with date, NPI, legible signature) instead of the 'meat' (the actual clinical needs and medical necessity),” wrote Maryanna Hart, AR coordinator for Van's Medical Equipment of Lakeland in St. Joseph, Mich. “It's adding to higher administrative costs.”

It is also affecting beneficiary access to products and services, respondents say.

“It's creating a lot more delays for patients getting their equipment as we are scrutinizing documentation much more closely,” wrote David Chesnut, owner of Pennyrile Home Medical in Cadiz, Ky.

Some respondents say they've gone as far as to refrain from providing products and services that are consistently denied or would warrant an appeal.

“We are losing business because we will not supply over the max allowed for urology supplies,” wrote Donna Barraclough, customer service manager for Apple West Home Medical Supply in Emeryville, Calif. “You can't really cut down on how much urine you produce without a significant change to your overall health. Our customers who have had over the max in the past are now suffering because they must cut down on use.”