Appeals backlog soars, solutions don’t appear imminent

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Friday, November 14, 2014

WASHINGTON – Less than a year after a massive appeals backlog at the Administrative Law Judge (ALJ) level first came to light, that backlog has nearly tripled.

“They confirmed that there’s more than 900,000 appeals in the backlog and they are getting 14,000 a week,” said Kim Brummett, senior director of regulatory affairs for AAHomecare. “Do the simple math: with 72 ALJs, even with no new appeals, they will catch up in 12.5 years.”

Brummett, along with Jay Witter, senior vice president of public policy for AAHomecare, met with staff of Chief ALJ Nancy Griswold on Nov. 12 to discuss the appeals backlog and possible solutions to relieve the burden on HME providers.

“I think they are willing to work with us, but the scope of what they can do is limited,” said Brummett. “We’re all screaming, ‘stop the audits until you catch up,’ but that’s not within their purview.”

The industry first learned of the appeals backlog when Griswold said in a Dec. 31, 2013, memo that the Office of Medicare Hearings and Appeals (OMHA) had seen its workload increase 184% since 2010, resulting in a then-backlog of 357,000 appeals. As a result, OMHA has suspended the assignment of hearings for appeals.

At an Oct. 29 forum, OMHA officials suggested, to the dismay of HME stakeholders, that providers need more education on documentation. With approximately 56% of ALJ appeals overturned, that simply doesn’t make sense, said Seth Johnson.

“It’s extremely frustrating and outrageous,” said Johnson, vice president of government relations for Pride Mobility, who attended the hearing. “The ALJ’s return rate indicates that the audit system is broken.”

For now, providers have only two options, neither of them promising for HME providers: the first is a pilot aimed at brokering settlements between the provider and CMS; the second is a statistical sampling initiative in which a payment decision is based on a random sampling of claims. Both options are limited in scope and could place burdens on providers, says Brummett.

OMHA has also issued a request for information, published in the Nov. 5 Federal Register, seeking input on current initiatives being undertaken by the ALJs, as well as suggestions for additional initiatives.

“That’s a good start and we are appreciative of the opportunity,” said attorney Steve Azia, counsel at Baker Donelson. “But the bottom line is that the process needs to be fixed. We are seeing a massive amount of denials for claims that should not be denied.”

 

 

 

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YES IT SEEMS THAT THE AUDIT REVIEW STEPS ARE BROKEN. THIS IS WHAT I HAVE FOUND IN AUDITS FOR US.  WE ISSUE EQUIPMENT WE RECEIVE AN AUDIT REQUEST. THE INFORMATION IS FAXED AND IT IS DENIED FOR EXAMPLE "NO DWO RECEIVED" IT IS THEN FAXED TO REDETERMINATIONS AND DENIED FOR THE SAME REASON "NO DWO RECEIVED". THE DWO IS IN THE PACKAGE FROM THE BEGINNING SO COPIES ARE MADE AND DWO IS WRITTEN ON THE ORDER.  IT IS STILL DENIED FOR THE SAME REASON. MAYBE ONE OR TWO WILL BE APPROVED. IT IS NOT THE ALJ WITH THE PROBLEM IT IS THE PEOPLE REVIEWING THE INFORMATION ON THE FRONT END. MAYBE IF THEY WERE FINED FOR WRONGFUL DENIALS THEY WOULD LOOK CLOSER AT THE PAPERWORK SENT IN AND APPROVE FROM THE BEGINNING.  I WENT TO THE WIZARD AND SINCE JUNE 2014 I AM RECEIVING AN AVERAGE OF 15 AUDITS PER WEEK. IF YOU REVIEW A PERCENTAGE OF CLAIMS AND FIND NO ERROR THEN CUT BACK AND FOLLOW UP ON THE ONES WITH THE ERRORS. THIS HAS GOTTEN OUT OF HAND AND IT  IS NOT THE PROVIDERS FAULT THE DENIALS ARE UNFOUNDED AND BACKLOGGING THE SYSTEM. WE AS PROVIDERS SHOULD NOT HAVE TO WAIT OVER 2 YEARS FOR A HEARING OR EXCEPT A % OF PAYMENT FOR EQUIPMENT WE HAVE PROVIDED AND FOLLOWED THE GUIDELINES. 

SIGNED FRUSTRATED WITH THE SYATEM.