Auditors avoid appeals process, make ‘major’ requests

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Wednesday, November 27, 2019

YARMOUTH, Maine – If you’re an HME provider trying to appeal a denial by a managed care payer, it’s probably not going very smoothly, reports consultant Wayne van Halem.

“There’s a process for appeals they have to follow that’s outlined in the managed care manual and they’re not doing that,” said van Halem, president of the van Halem Group.

The process is similar to Medicare’s: a number of levels of appeals, including redetermination, reconsideration and administrative law judge or ALJ.

Instead of going through the process, the third parties that the managed care payers have hired to conduct their audits are pressuring providers to settle—and they’re not being very subtle about it, van Halem says.

“We’ve seen it happen five or six times this year, primarily to out-of-network providers,” he said. “They’ll even come back and say, ‘If you don't settle, we’ll audit 100% of your claims.’”

This was also an issue several years ago, van Halem says.

“CMS said at the time that they were aware the payers were not familiar with the appeals process but that they felt the issue was being resolved,” he said. “Now it’s popping back up again.”

van Halem encourages providers to understand the process and know their rights.

“Don’t just succumb to whatever these third parties say,” he said.

Speaking of auditors, consultant Sylvia Toscano reports “major activity” from the RACs on lymphedema pumps.

“They’re selecting too many files for a provider’s volume,” said Toscano, owner of Professional Medical Administration. “You have a mid-sized provider and they’re getting hit with a couple hundred files. That's a whole year of billing for some of them.”