Appeals backlog wears on

‘Hopefully we’re still in business when our cases get to a judge,’ says provider Donna Barraclough
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Friday, May 19, 2017

YARMOUTH, Maine – A whopping 92% of respondents to a recent HME Newspoll say they have claims stuck at the administrative law judge level and are waiting—and waiting—for hearing dates.

The largest majority of poll respondents (28%) say their claims are going on three years old.

“This is a major cash flow problem,” wrote Mary Klavoon of Buffalo Wheelchair in Buffalo, N.Y. “We buy and pay for equipment, and dispense to our qualified Medicare recipients, only to have to wait three to four years to have something reviewed and hopefully paid.”

At last count, 884,017 appeals were waiting to be adjudicated by the Office of Medicare Hearings and Appeals. Using its current resources (and without any additional appeals), it would take OMHA 11 years to process that backlog.

Poll respondents say their businesses could fold, their patients could die—all by the time they’re scheduled for hearing dates to review their appeals.

“We are a small business; if too many claims go to higher levels, this could jeopardize us staying in business,” wrote Donna Barraclough of Apple West Home Medical Supply in Emeryville, Calif. “We evaluate our case and if we feel we can win, we continue to appeal. Most denials are for reasons that can usually be overturned at the higher levels. If we lose, we learn more ways to help us make sure that future claims pass audits. Hopefully we’re still in business when our cases get to a judge. We recently won two cases from 2013.”

And therein lies the biggest frustration for many poll respondents: In the large majority of cases (as much as 90% of the time, according to stakeholder estimates), they win on appeal, meaning the claims should never have been denied in the first place.

“It’s very frustrating to see these same names over and over again on reports, servicing them and knowing that you are not being paid a dime,” wrote Ken Wells of Tucker-Wells Medical in Florence, S.C. “All of the claims were rejected for miniscule things or in error, and should have never been rejected. I appealed because I know that I will win 100% of them.”

Despite their frustrations, poll respondents say they continue to appeal claims because they have few other options—and they do it on principle.

“It’s killing us, but yes, we continue to appeal, otherwise the bad guys win,” wrote Terry Pinto of Home Medical in Aiken, S.C.