Whoa, Nellie: This thing is out of control

Jonathan Temple

If you remember The Roy Rogers Show, you might remember Roy's sidekick, Pat, driving the old Jeep nicknamed Nellie Belle. On occasion, Nellie Belle would get out of control and Pat would yell, “Whoa Nellie Belle." (It was shortened by most people to just plain "Whoa Nellie.") Today, we have a different vehicle out of control: Medicare. Someone needs to holler "Whoa Nellie!” and put a stop to this runaway, out of control renegade before someone gets hurt.

Home medical equipment (HME) providers, hospitals, physicians, and home health and hospice agencies have been assaulted by an unprecedented numbers of audits. The latest numbers show that in the first quarter of fiscal year 2013, the recovery audit contractors (RACs) collected $744.8 million in overpayments. And while providers in all four regions were hit hard, those hit the hardest were in Region C, which had to pay back $244 million in the first quarter of 2013. This is only expected to grow. As reported in Decision Health Daily's recent Red Alert, CMS is paying bounties to a new private corporation. A fifth RAC will have jurisdiction nationwide over just HME and home health and hospice. This expands on the four existing RACs, which have limited jurisdiction by state.

On Feb. 12, the Office of Medicare Hearings and Appeals (OMHA) hosted a very informative and eye opening Medicare Appellant Forum. The purpose was to provide updates to appellants on the status of OMHA operations and relay information on a number of OMHA initiatives designed to mitigate a growing backlog in the processing of Medicare appeals at the administrative law judge (ALJ) level.

These numbers, released by OMHA, will make you yell "Whoa Nellie” over and over! When a request for a hearing is made, requests are mailed to OHMA and processed manually. The average response time to acknowledge that the OMHA request for a hearing was received is 18 to 22 weeks, or almost 6 months. There are 65 judges hearing cases, Chief ALJ Nancy Griswold reported. Judges are hearing, on average, 4.9 cases per day. It would take 65 judges 3,061 days to rule on one week's worth of cases.

Other stats shared at the forum:

  • OHMA receives 15,000 cases per week
  • OMHA has 375,000 cases assigned to be heard
  • There are 480,000 cases waiting to be assigned to a judge.
  • There are 220,000 cases waiting to be added to the OMHA system, manually.
  • It’s 28 months until a case is assigned to a judge
  • 177,283 cases have been assigned through July 15, 2014
  • Once a case is assigned to a judge, the average days to a decision is 329.8 days—and that's after it gets assigned

During the forum, a panel of judges took questions from attendees. Many of the attendees offered the opinion that the tremendous backlog of cases is due to the massive amount of denials at the lower level of appeals and asked what could be done to provide relief.

Griswold expressed several times that OHMA is looking at a "holistic" approach to the challenge that OHMA faces. OHMA is seeking to digitize claims so that they can be processed electronically, said Bruce Golden, director of information management. Golden spoke about OHMA's IT efforts to help process claims. A program called ESCAPE (yeah, right) should be ready to launch by 2016 (Don't hold your breath).

I wish Pat from The Roy Rogers Show was around today to yell, "Whoa Nellie!" so that someone would listen and stop this madness. Those were the good ole days, but the good ole days are gone and Roy is not around to help. It is up to suppliers to yell out, loud and clear!

Jonathan Temple owns OxyMed in Birmingham, Ala.