Appeals process could lose appeal

YARMOUTH, Maine - HME providers have heard it a million times: If you are getting audited, appeal early and appeal often.

But, with the recent revelation that the Office of Medicare Hearings and Appeals has a backlog of nearly half a million appeals and has stopped assigning new cases to the administrative law judges (ALJs) for as long as two years, it may be time to reconsider that, say industry stakeholders.

“When you are waiting two-and-a-half years for a decision at the ALJ, you are going to have to make some decisions,” said Stephanie Greene, president of Morgan Green Consulting. “Is it worth it?”

In cases where it's not worth it, it may be better to treat the patient as a new patient, say stakeholders.

“If you have a claim denied, say for oxygen, you can start the patient all over,” said Kim Brummett, senior director of regulatory affairs for AAHomecare. “Go back to the physician and re-do everything.”

But that isn't a possibility for certain items, like custom prosthetics.

“Those folks can't just refund the money and start over,” said Wayne van Halem, president of The van Halem Group. “That's a limb that the provider has paid, in some cases, $30,000 for and Medicare is trying to recoup $40,000.”

Rather than putting providers in the position of having to decide whether or not to appeal, the system needs to be fixed, say stakeholders.

“I would not pin this on providers,” said Steve Azia, counsel at Baker Donelson. “Are there cases where claims are going to be rightfully denied? Yes, but the cases that go to the ALJ are cases that need to be heard.”