Audits: 'We are in crisis,' stakeholders say

WASHINGTON - HME stakeholders made their case against an audit program run amok at a forum last week.

“We need to have a resolution on how to help my providers today because we are in crisis,” said Tom Ryan, president and CEO of AAHomecare, who attended the daylong event on Feb. 12. “The system is broken and it needs to be fixed.”

The Office of Medicare Hearings and Appeals (OMHA) hosted the forum to discuss an increased workload that has led to a backlog of 460,000 appeals and the suspension of the assignment of appeals to the administrative law judges (ALJs) for up to two years.

Stakeholders received a sympathetic ear from Chief ALJ Nancy Griswold.

“She was adamant that she gets it that two or three years of holding somebody's cash flow is going to kill some of these businesses,” said John Gallagher, vice president of government relations for The VGM Group, who also attended the forum. “They want to expedite that.”

OMHA's presentation detailed some initiatives aimed at making the process more efficient, including the increased use of technology and a website that will allow providers to view the status of their appeals.

But after multiple stakeholders complained about claims denied due to technical reasons during a question and answer session, it became clear to OMHA that the bulk of the problems may happen before they reach the ALJ level.

“It isn't the ALJ that is the issue, it is CMS at levels 1 and 2,” said Gallagher. “They said they didn't know there were technical issues. Griswold said that we've got to be holistic and look at this from all angles.”

The bottom line is that there is simply too much audit activity on the front end, particularly with the RAC audits, says Ryan.

“Nothing is going to work if you don't stop pushing it in at the top,” he said.

One thing the industry would like to see: a way to separate appeals for claims denied due to technical reasons from all other appeals. That would create a compelling picture of just how badly the system is broken, said Ryan.

“I am hoping we get the dialogue, but the dialogue has to be with OMHA and CMS,” he said. “We've got the olive branch out.”