Stakeholders wait on bill as appeals backlog grows

Friday, June 26, 2015

WASHINGTON – Industry stakeholders say, despite slow progress, the reintroduction of an audit reform bill is still a “high priority.”

They had hoped to see Rep. Renee Ellmers, R-N.C., drop the bill this spring.

“Obviously, we wanted it sooner than this,” said Beth Bowen, executive director of the North Carolina Association of Medical Equipment Services, who’s been working with Ellmers on the bill. “It’s still in the works, still a high priority.”

The hold up? At least one member of the House Ways and Means Committee has issues with a provision in the bill reinstating clinical inference. This would allow audit contractors to make common sense judgments on whether claims should be paid, rather than denying them just because of technical issues.

“If the bill is introduced without clinical inference it won’t make any sense,” said Tom Ryan, president and CEO of AAHomecare. “I think some of the pushback from the committee is probably coming from lobbyists for the Recovery Audit Contractors.” 

Since the elimination of clinical inference in 2009, error rates for HME have soared, from less than 10% of claims to more than 60% of claims denied for technical reasons, stakeholders say. 

Ellmers’ previous audit reform bill, introduced in July 2014, included a provision to reinstate clinical inference.

Meanwhile, the backlog of appealed claims at the Administrative Law Judge level continues to grow, said Chief ALJ Nancy Griswold during a forum on June 25. During the first quarter of 2015, 128,000 appeals were filed, with an average processing time of 588.9 days, she said.

“We are seeing sustained growth in appeals due to a number of factors,” she said. “We’ve seen across-the-board increases not only from RACs, but also from other post-pay audit programs, more active state Medicaid agencies, and more beneficiaries aging into the program.”

OMHA is working with CMS to resolve issues surrounding the appeals workload, Griswold said, including trying to resolve cases earlier in the process.