Poll: 41% have been waiting at least one year for hearing
YARMOUTH, Maine – Long delays have made appealing denied claims a painful process for HME providers, forcing them to wait sometimes years for payment.
Nearly all of the 120 respondents to the December HME NewsPoll (91%) say they have one or more appeals awaiting a hearing with an administrative law judge (ALJ), the third level of appeal. Forty-one percent of respondents say they’ve already been waiting at least a year.
“Many of these claims are showing up as open invoices on our books and presenting a poor financial picture for our company because of outstanding revenue,” one respondent said.
Things could get worse: The Office of Medicare Hearings and Appeals recently announced that it will defer assignments for hearings with an ALJ up to 28 months.
While a 2012 report from the Office of Inspector General found that the ALJ ends up approving 56% of denied claims, the delays make getting there costly, respondents say.
“This patient continues to need and use the power wheelchair, which we are nice enough to let him use while we wait for the ALJ, making us the banker,” one respondent said.
Some respondents say they are no longer willing or financially able to go through the process, leaving beneficiaries on their own to appeal, or to pay out of pocket.
“If a CPAP is denied at any point, then that patient is no longer able to get supplies on an assigned claim basis,” said Clark Robichaux of Wilmington, N.C.-based Oxy-Care. “They must pay up front. While we have never lost in the ALJ process, we are not willing to invest additional money for the period it takes to get a hearing.”
Other respondents say they stick it out because it’s the right thing to do.
“Until this ALJ is approved for the months that were denied, we have been providing enteral services to this patient every month at our expense because it is a life saving measure,” one respondent said. “If we do not supply this to him, the patient will not survive and we cannot rightly turn him away because Medicare doesn’t think he qualifies, when we know he surely does.”