AAHomecare Advances Agenda for Battling Audit Backlog

Video: Association's Pres. Ryan spoke at OMHA Appellant Forum last week; slated to meet with Chief ALJ Griswold next week.

• By David Kopf
• Nov 06, 2014

In addition to pursuing a legislative fix through the Audit Improvement and Reform Act (AIR Act; H.R. 5083), the American Association for Homecare is also trying to work with CMS’s Office of Medicare Hearings and Appeals to bring the deteriorating audit and ALJ delay situation under control.

As it stands, OMHA is still delaying assigning Administrative Law Judges to appeals by more than two years in order go buy time to churn through more than 600,000 appeal cases awaiting ALJs.

So, AAHomecare attended the OMHA Appellant Forum last week and is meeting with OMHA’s Chief Administrative Law Judge Nancy Griswold next week in hopes of directly working with the office to fix the problem. Also, AAHomecare will respond to this request for information from OMHA by its Dec. 5 deadline for input.

“I have providers that can’t make payroll every day … they’re going out of business,” AAHomecare President and CEO Tom Ryan commented at OMHA’s Appellant Forum, noting that current efforts by CMS and OMHA to solve the backlog are taking too long. “Clearly there are things that we can do that I think would help with the backlog.”

Ryan presented some ideas that are provisions within the AIR Act, which contains various provisions for solving an audit problem that Ryan said has put providers “in a crisis.” Two key elements he mentioned were related to the timely filing limits, which are contributing to the backlog, and the restoration of clinical inference, which should reduce claims on CERT audits, which have a high level of overturn at the ALJ level of appeals.

“These are all parts of legislation we have pending,” he noted. “But I hate to have to continually go to the Hill to legislate to fix this.”

Ryan’s comments:

OMHA public request input covers not only feedback on the current initiatives being undertaken at the Administrative Law Judge level, but also suggestions for additional initiatives that OMHA could undertake to address the Medicare claim and entitlement appeals workload and backlog at the ALJ level.

Key provisions of the AIR Act  include:

• Providers will receive a score on their error rates. Suppliers with low errors rates will receive fewer audits.
• Providers with error rates of 15 percent or lower will only be subject to one random audit for the year they have a low error rate.
• Clinical inference and clinical judgment when evaluating audits is restored in the audit process.
• Look-back periods are limited to three years rather than five years for MACs and four years for RACs.
• MACs and RACs must provide quarterly training on avoiding frequent payment errors, including notice of all new audit procedures and education to avoid clerical errors. Funding for these programs will be derive from 25 percent of recoupments.
• Requiring the reporting of error rates on audited claims after adjustment for those audited claims that have been overturned on appeal.