A call to take on audits

Friday, February 21, 2014

Times are trying for our industry, but it’s during these times that leaders rise to the top. In the past years, as we’ve taken on the competitive bidding issue together, I’ve seen our providers transform into leaders, writers, organizers and advocates. We’re getting better at telling our stories, engaging patients and taking our issues to Congress. Participation in the legislative process is increasing. It’s the hard times that make these transformations occur.

In light of Chief Judge Nancy Griswold’s memorandum, which suspended the assignment of appeal requests to administrative law judges for two years, it’s now time to take on the audit issue. Where in America is it acceptable to deny due process, as this backlog issue has done to DME providers and Medicare beneficiaries? CMS entrusts the care of beneficiaries to providers and at the same time robs them of the cash flow needed to keep their businesses open and provide for patients. 

These mindless audits that prioritize technicalities over medical necessity have to stop.

The Feb. 12 Appellant Forum highlighted the details of a broken system that has lead to an astonishing 460,000 backlogged appeals. The average wait time for a hearing before an administrative law judge is 16 months, and most of us know it to be even higher. That number continues to rise. 

This public admission of failure to provide the due process that impacts business owners, senior citizens and people with disabilities is a catalyst for change. Now it’s our job to get busy telling the story.

We must return to action and take the lessons we’ve learned while fighting competitive bidding to the issue of audits. Together we need to push for the following remedies:

• Suspend the CMS audit programs immediately to resume only when an effective timely appeal channel is available to all providers.

• Stop recoupments on current claim denials that are waiting an ALJ hearing.

• Refund recoupments that have already occurred if appeal was made after July 15, 2013, during the suspension of the appeal process.

• Prioritize medical necessity over technical issues that trigger denials at the first and second levels.

• Support reform legislation to require fairness in audit programs, including a fast and effective independent appeal program that protects the Medicare program, beneficiaries and providers.

Current legislation addressing the audit issues focuses on hospitals and does not include DME. H.R. 1250, the Medicare Audit Improvement Act of 2013, sponsored by Rep. Sam Graves, R-Mo., and S. 1012, sponsored by Sen. Roy Blunt, R-Mo., have gained 180 and 10 co-sponsors, respectively. 

It’s our role to express to these sponsors and other congressional members the importance of DME and the crippling nature in which the audits are impacting our industry. Our message to Congress is that DME is a critical component of the healthcare continuum, which includes hospitals and pharmacies, and must be included in the Medicare Audit Improvement Act.

H.R. 1250 and S. 1012 have great potential for movement and we have reason to believe that Rep. Graves and Sen. Blunt will take on our issue. I will work with Missouri providers to reach out to them. In other parts of the country, providers must reach out to their congressional members to raise awareness, as well.

At VGM, we have the tools you need to be vocal and continue the fight. You can contact Congress by email at any time from our website, www.vgmdclink.com, where we have pre-written sample letters to get you started. We will host regular Hill and in-district events during the next many months, which we will highlight on our website and through my regular updates. And don’t forget that we have People for Quality Care available to you when you have patients who are willing to speak out.

The time is now to take on audits. We will use the lessons we have learned in the competitive bidding fight to bolster both efforts. To our faithful providers—leaders who have shown so much through the years—it’s time to go to battle again. Our story may not be the celebrity coverage of every day headlines, but darn it, we’re going to make sure it’s heard.

John Gallagher is vice president of government relations for The VGM Group. Reach him at john.gallagher@vgm.com or 319-235-7100.