Analysis reveals worsening appeals backlog

WASHINGTON - The wait time for DME appeals at the administrative law judge level has increased by nearly 25% during the first half of 2015, according to an analysis released by AAHomecare.

“It is painfully obvious that this system is broken, but no measures are being taken to fix the root of the problem,” said Kim Brummett, vice president of regulatory affairs at AAHomecare, in a release.

Despite reports from the Office of Medicare Hearings and Appeals indicating improvement, the average processing time at the ALJ level was 725 days in June, according to data that AAHomecare analyzed from the OMHA website.

By law, providers who file an appeal at the ALJ level must receive a decision within 90 days. However, due to the sheer number of appeals received, OMHA has suspended the assignment of hearings for appeals.

The result: the number of claims held at the ALJ level has gone from 38,506 in 2006 to 364,634 in 2015, a 947% increase.

The number of appeals for DME at the ALJ level has skyrocketed from 6,305 in 2006 to 133,839 in 2014, a whopping 2122% increase.

That's in part due to the specific nature of providing DME products and services, Brummett says.

“Home medical equipment providers are dealing with the same patient and same service/item on an ongoing basis over a period of time,” she said.  “When the first claim is denied, all of the subsequent claims for the same patient and service are denied. However, when the previous claim is overturned, it does not mean that any other claims for the same patient and same service will be paid/overturned at any level. This cycle traps a large volume of claims in a system that cannot handle them properly.”

If this trend continues, OMHA will have 3 million appeals by the end of 2016, AAHomecare says.