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Tag: Appeals

Andrea Stark


Andrea Stark makes case for making demo permanent

September 10, 2021Liz Beaulieu, Editor

YARMOUTH, Maine – The contract may be running out for a demonstration that allows HME providers to try to resolve denied claims by phone, but Andrea Stark says, “We’re onto something here,” and hopes CMS will make it a permanent part of the statement of work for the QIC.  The QIC, which is run by Maximus, recently announced it is winding down the demo per a contract that ends Dec. 31, 2021.  “Clearly, DME is complicated and suppliers feel better when...

Andrea Stark, Appeals, Home Medical Equipment, QIC

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Also Noted

DME appeals represent 42% of ALJ backlog, AAH says

March 12, 2021HME News Staff

WASHINGTON – The Office of Medicare Hearing and Appeals (OMHA) has shared with AAHomecare that there were 201,292 appeals in the ALJ backlog at the end of 2020, about 85,000 of which involved DME. That’s a significant drop from 2019, the association says, when there were 318,000 appeals in the ALJ backlog, about 173,000 of which involved DME. In past years, DME appeals have represented up to 55% of the ALJ backlog, AAHomecare says.

Administrative Law Judge, Appeals, DMEPOS, Office of Medicare Hearings and Appeals


CMS expands phone demo

October 23, 2018HME News Staff

JACKSONVILLE, Fla. - CMS will expand a demonstration project that allows HME providers to speak with reconsideration professionals by phone to try and resolve their cases to jurisdictions A and B on Nov. 1.The agency cited “strong support from the supplier community and the initial success of the demonstration” as reasons to expand the phone demo.“Effective on or after Nov. 1, the DME QIC will offer telephone discussions and/or re-openings to DME suppliers within the DME MAC Jurisdictions...

ALJ, Appeals, C2C Innovative Solutions, Phone demo, QIC

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Court agrees broken appeals systems is unfair

June 22, 2018Liz Beaulieu, Editor

DALLAS - A U.S. District Court's recent opinion prohibiting CMS from recouping alleged overpayments from a provider going through the appeals process until after the administrative law judge level sends a strong message, industry stakeholders say.As part of the June 4 opinion, Judge Ed Kinkeade of the U.S. District Court for the Northern District of Texas agreed to issue a temporary restraining order against CMS, the latest development in Family Rehabilitation, Inc. vs. Azar.“The system, which...

ALJ, Appeals, Backlog, Medicare, temporary restraining order

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Regulatory updates: Low volume appeals, prior auths

April 5, 2018HME News Staff

CMS will be accepting expressions of interest for low volume appeals from April 12-June 8, 2018, for all NPIs. An EOI must be submitted for each NPI. The appeals are only offered to appellants that have less than 500 appeals sitting at OMHA and/or the Medicare Appeals Council as of Nov. 3, 2017, and each appeal must have a total billed amount of $9,000 or less. More information can be found here…CMS has removed the following items from the prior authorization Master List: hospital bed semi-electric...

Appeals, Home Medical Equipment

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Appeals update: Pressure mounts to expand phone demo

December 15, 2017Liz Beaulieu, Editor

WASHINGTON - CMS is considering expanding a demonstration project to jurisdictions A and B that allows providers to speak with reconsideration professionals by phone to try and resolve their appeals at the second level, stakeholders say.After hearing testimony from Ronda Buhrmester at a recent Small Business Administration hearing, CMS responded in a letter, saying it “concurs with the noted initial benefits of this demonstration and is in discussions regarding possible expansions to jurisdictions...

Appeals, C2C, Phone demo, QIC

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HHS details status of appeals backlog

November 29, 2017HME News Staff

FALLS CHURCH, Va. - The Office of Medicare Hearings and Appeals receives more than a year's worth of appeals work every 24 weeks at the third level of appeals, according to a recent PDF posted to the agency's website.As of the end of the fourth quarter of fiscal year 2016, the pending workload at the administrative law judge level exceeded 650,000 appeals, while annual adjudication capacity going forward was about 92,000 appeals, according to the “HHS Primer: The Medicare Appeals Process.”At...

ALJ, Appeals, Backlog, OMHA

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Medtrade Show Daily

Session spotlight: Be prepared for your day in court

October 24, 2017Jeff Rowe

ATLANTA - Many HME providers end up in front of an administrative law judge to contest a reimbursement denial, but too often they don't know what they're up against, says speaker Ross Burris.In the session “What Really Happens In An ALJ Hearing?” today at Medtrade, Burris, an attorney with Polisinelli, will be part of a panel that will walk attendees through how to prepare and manage an ALJ hearing.HME News:Why is there a need for a session like this?Ross Burris:A lot of providers decide...

ALJ, Appeals, Ross Burris

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In brief: HHS scores win in appeals fight, Superior HealthPlan makes changes to Medline contract

August 18, 2017HME News Staff

NEW YORK - The D.C. Circuit on Aug. 11 ordered a federal judge to take a deeper look at whether or not the U.S. Department of Health and Human Services can clear a backlog of about 600,000 appeals by 2021, while still protecting taxpayer dollars, according to Law360. The ruling is a setback for the American Hospital Association, which has been fighting HHS in court over the backlog for several years. The D.C. Circuit, in a 2-1 ruling, said the judge didn't properly evaluate HHS's assertion that it...

Appeals, Audits, Managed Care, Medicaid

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Appeals backlog wears on

May 19, 2017Liz Beaulieu, Editor

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...

Administrative Law Judge, ALJ Backlog, Appeals, Audits

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