Industry to OMHA: Audit Process Is Broken

AAHomecare’s Ryan tells OMHA’s Griswold that ALJ delay has put providers in ‘crisis mode’ and a fix is needed fast.

Various HME industry representatives warned the Office of Medicare Hearings and Appeals (OMHA) about the serious threat posed to patients and providers by the office’s decision to delay the assignment of Administrative Law Judges (ALJs) to Medicare audit appeals by two years.

Wednesday’s OMHA Appellant Forum in Washington D.C. began with several presentations regarding the OMHA backlog of 164,000 appeals, which is the reason the office cited for the suspension of assignment of appeals cases to ALJs.

Question-and-answer opportunities, which were heard by Chief Judge Nancy Griswold and several Administrative Law Judges, included representatives from the American Association for Homecare, state associations, the VGM Group and individual providers. The HME constituents raised concerns about how the delays and audit inconsistencies were negatively impacting business and service to beneficiaries.

Peggy Walker, RN, Billing and Reimbursement Advisor for US Rehab/VGM
addresses Griswold and other OMHA representatives.

Photo courtesy of Tom Powers, VGM Government Relations

Industry Comments

AAHomecare President Tom Ryan told OMHA's Griswold that the ALJ assignment delays along with denials and audits of claims for patients that were longtime DME users is evidence that the audit process is broken. Moreover, the delays have put providers into "are in crisis mode," he added. The recouped funding, delays and potential fines pose severe financial implications for providers.

Ryan said the industry welcomed OMHA's long-term plans to use technology and other means to streamline the hearing process, but because the current system is dysfunctional on every level, providers need immediate relief. So, the AAHomecare leader asked Griswold for solutions beyond legislation that would have an immediate impact, and said his association’s Audit Task Force as ready to work with OMHA, and would like to schedule meetings in the near future.

NCART Executive Director Don Clayback 
prepares to speak.

Photo courtesy of Tom Powers, VGM Government Relations

Several questioners addressed the issue of technical and clerical denials that were being raised as high as the ALJ level, when they could be adjusted by contractors at the lower Level I & II. Another suggested that since the process is so backlogged and inconsistent that providers should keep the Medicare payments until the final decision is reached.

OMAH Response

Griswold defended OMHA’s processes, but acknowledged the many concerns voiced at the forum, and said she understood that the decisions are affecting business and beneficiaries.

Griswold said that the judges are still hearing cases, but that their workload has increased considerably: from 1,200 to 15,000 appeals per week since January 2012. She said growth in appeals was anticipated due to the growing population of new Medicare beneficiaries, but not an increase of the order OMHA has experienced.

Currently projections indicate an 18 to 22 week delay in entering new requests into the ALJ case processing system. The average processing time for appeals decided in fiscal year 2014 is 321.6 days.

Griswold encouraged providers to continue filing appeals despite the long delays, and advised the following:

  1. They should file their requests for a hearing only once.
  2. Hold the extra paper, exhibits and similar materials until the case has been assigned to a specific judge.
  3. Check the ALJ website for processing times and delays.

Moving Forward

Coming out the meetings, Joseph Reutter of BSI Medical Supply, who was part of a team of 20 VGM representatives, noted that “the ALJ is not the problem.”

“CMS is the main problem here,” he explained. “And the first two rounds, re-determination and reconsideration, are the biggest issues.”

The VGM team of continued their efforts by making visits on Capitol Hill today. The association noted bad weather conditions could force the cancellation of some meetings, but the group was ready to lobby.

“Armed with their experience at the OMHA Forum, they are motivated to express their concerns to members of Congress,” John Gallagher, VGM vice president-government relations.”

About the Author

David Kopf is the Publisher and Executive Editor of HME Business and DME Pharmacy magazines. Follow him on Twitter at @postacutenews.

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