Senate Hearing Highlights Audit Debacle

Senate Finance Committee explores problem of audit backlog, reviews possible methods to reduce problem.

Senate Finance Committee Chairman Sen. Orrin Hatch (R-Utah) said the mounting backlog of Medicare audit appeals backlog has not only delayed payments to providers, but also blocked Medicare coverage for beneficiaries, at a special hearing concerning the backlog of Medicare claims appeals at the administrative law judges (ALJ) level.

Hatch said appeals are taking an average of 547 days to be processed in fiscal year 2015, which is “far too long for beneficiaries to find out whether their medical services will be covered or for providers to find out if they will be paid."

Attending the hearing on behalf of the American Association for Homecare were Jay Witter, senior vice president of government affairs; Peter Rankin, assistant director of government affairs; and Ashley Jackson, government affairs associate.

The committee heard testimony from Nancy Griswold, the chief Administrative Law Judge for CMS’s Office of Medicare Hearings and Appeals (OMHA), as well as two Medicare contractors involved in the first two levels of the appeals process. Sandy Coston, chief executive officer and president of Medicare contractor Diversified Service Options, told the committee appeals at the ALJ level should be sent back to the previous appeals level when new evidence is submitted, an idea also supported by the OMHA.

“In cases where new evidence is submitted at the ALJ level, remanding these case back to the prior level for handling would result in a reduction in the ALJ backlog, as well as quicker resolution for the providers,” Coston said.

Thomas Naughton, a senior vice president with MAXIMUS Federal Services, a Medicare Qualified Independent Contractor (QIC), testified the appeals backlog could be reduced by establishing a support unit for ALJs capable of providing expertise on RAC audits. The unit would provide subject matter experts such as nurses, physicians and certified coding specialists, who could help the ALJs resolve appeals.

Also, transitioning to electronic document submission throughout the appeals process would provide “significant time and cost efficiencies while ensuring access to the complete case file,” Naughton added

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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