In brief: HHS details status of appeals backlog, supplier dropped from lawsuit

 - 
Friday, December 1, 2017

FALLS CHURCH, Va. – The Office of Medicare Hearings and Appeals receives more than a year’s worth of appeals work every 24 weeks at the third level of appeals, according to a recent PDF posted to the agency’s website.

As of the end of the fourth quarter of fiscal year 2016, the pending workload at the administrative law judge level exceeded 650,000 appeals, while annual adjudication capacity going forward was about 92,000 appeals, according to the “HHS Primer: The Medicare Appeals Process.”

At the first and second level of appeals, CMS is currently meeting its statutory timeframes to process appeals and is not experiencing a backlog, HHS says.

At the fourth level of appeals, the Medicare Appeals Council is currently receiving more than a year’s worth of appeals work every 10 weeks. As of the end of the fourth quarter of fiscal year 2016, the pending workload at the council exceeded 22,000 appeals, while annual adjudication capacity was about 2,600 appeals, HHS says.

Several companies are generating a significant portion of the appeals backlog, HHS says. Four DME companies and one state Medicaid agency filed 51% of appeals at the ALJ level in the first quarter of fiscal year 2015, it says. Three DME companies filed 35% of the appeals at the second level of appeals, or the QIC level, in 2015 compared to just 12% in 2012.

HHS says the current appeals structure encourages appellants to appeal every claim because there is no filing fee and because the minimum amount in controversy required for an ALJ hearing, $160, is substantially lower than the amount required for judicial review, $1,560.

HHS says it has a three-pronged approach to addressing the backlog and improving the system: invest new resources at all levels of appeal to increase adjudication capacity and implement new strategies to alleviate the current backlog; take administrative actions to reduce the number of pending appeals and encourage resolution of cases earlier in the process; and propose legislative reforms that provide additional funding and new authorities to address the appeals volume.

Without administrative action, HHS estimates the appeals backlog at OMHA will exceed 1.5 million by the end of fiscal year 2021.

Bid relief bill adds co-sponsors

WASHINGTON – A bill that would provide relief from the competitive bidding program now has 76 co-sponsors, AAHomecare and VGM Group report. H.R. 4229, introduced Nov. 2 by Rep. Cathy McMorris Rodgers, R-Wash., with 53 original co-sponsors, would extend a retroactive delay of a second round of reimbursement cuts in non-bid areas from Jan. 1, 2017, to Jan. 1, 2019. It would also address a “double dip” cut to oxygen therapy. The newest co-sponsors are Reps. Mark Meadows, R-N.C., Mike Coffman, R-Colo., Alexander Mooney, R-W.Va., Vicente Gonzalez, D-Texas, and Betty McCollum, D-Minn. More representatives are close to signing on to the bill, VGM says.

Diabetes supplier dropped from lawsuit

INDIANAPOLIS – J&B Medical Supply has been dismissed from a lawsuit alleging it had sold blood glucose test strips under the retail pharmacy benefit rather than the DME benefit.

All charges were dismissed without prejudice and without costs, according to a court filing.

The lawsuit, filed earlier this year by Roche Diagnostics and Roche Diabetes Care, claimed that they wrongfully paid millions of dollars in rebates in lost millions of dollars in legitimate sales to an alleged scheme by several pharmacies and medical supply companies.

J&B Medical at the time said it stopped purchasing test strips from Roche in 2009.

In addition to the Wixom, Mich.-based J&B Medical, the suit named several other Michigan companies: Binson’s Hospital Supplies and Northwood, both of Centerline; Olympus Global in East Lansing; and Delta Global in Flint; as well as Alpha XE in Cheyenne, Wyoming.

AOPA says O&P must remain essential health benefit

WASHINGTON – The American Orthotic and Prosthetic Association has submitted comments on a proposal to provide individual states with increased flexibility to define essential health benefits. In its comments on the “Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2019”, AOPA reiterated its position that orthoses and prostheses must remain essential health benefits and that any action by CMS to restrict or reduce access to O&P services is not in the interest of patient care. The association believes that expanding the authority of individual states to define what counts as EHB, will likely benefit insurers who look to reduce costs by limiting coverage. 

Blue Mint Pharmacy hunts for HME

HOUSTON – Blue Mint Pharmacy, a four-year-old online pharmacy, has added home medical equipment to its services to grow its customer base, it announced Nov. 29. It will not carry an inventory of HME but act as a “personal bargain hunter,” taking inquiries for specific equipment and searching across the country for the lowest available price. The company already uses this strategy for pet medications. “There is a need for affordable home medical equipment,” said CEO TJ Blackwell. “We want to make sure Americans can pay for and bring home the supplies they need to recover quickly from health events and enjoy a high quality of life with chronic conditions.” Blue Mint Pharmacy is a locally owned, full-service, independent pharmacy based in Houston. It specializes in retail and customized, compounded medications, and accepts most major insurance prescription plans.

Huggenberger, Whitfield tapped by Sommetrics

SAN DIEGO – Sommetrics, a maker of products focused on improving sleep quality, has named Raymond Huggenberger, former Inogen CEO to its board of directors, it announced today. Huggeberger has more than 20 years of experience in the healthcare industry. Prior to joining Inogen, he held leadership roles at Sunrise Medical. Sommetrics has also named Randall Whitfield to its advisory board. Whitfield has 15 years of experience in the respiratory field, including leading various business groups at Philips Healthcare, president of the business unit at Respironics and president of Puritan Bennett. Sommetrics recently partnered with AvantSleep to distribute its aerSleep sleep apnea therapy system in Canada.

BioScrip bolsters management team

DENVER – BioScrip has added two new execs to its management team: Harriet Booker as senior vice president and COO, and Danny Claycomb as senior vice president of revenue cycle management. Most recently, Booker was interim senior vice president of revenue cycle management for Option Care. She has also worked at Coram/CVS Specialty Infusion Services, Coram Specialty Infusion and Apria Healthcare. Most recently, Claycomb was senior vice president of revenue cycle management at Envision Healthcare. He has also worked at Coram/CVS Specialty Infusion Services, Coram Specialty Infusion and Medtronic. “On behalf of our board and management team, I am excited to welcome Harriet and Danny to BioScrip,” said Daniel Greenleaf, president and CEO, who joined BioScrip in 2016 after helping to turn around Home Solutions and Coram. “Harriet and Danny each have extensive industry experience in both public and privately held healthcare companies, and a proven track record of driving profitable growth, achieving targeted metrics, and motivating strong team performance.”

Vertess adds DME exec

TUCSON, Ariz. – Vertess, a healthcare M&A advisory firm, has added DME executive Eric Hymes as managing director. Hymes’ past experience includes a stint as general manager and senior executive with medical supplies provider CCS Medical, where he had responsibility for more than $100 million in P&L. “While my career in healthcare has always been focused on the end user and their families, the apex of my experience was successfully navigating an ever-shifting landscape of healthcare insurance policy and associated reimbursement pressures,” he said. “This created an environment where the most dynamic and well managed companies were always the market leaders and market survivors.” Hymes joined the M&A market in 2013, when he built a platform company in urological DME products and services, and then left the company as a “top 10 contender” in the market. At Vertess, he will focus on the DME (diabetes, insulin pump, orology, ostomy, incontinence, advanced wound care dressings) and specialty physician practice verticals.

Medtrade Spring 2018: Special early bird rates in effect

LAS VEGAS – SmartSaver registration rates for Medtrade Spring 2018 are now in effect. The SmartSaver rates are $25 for the expo and $99 for the conference, a big savings over early, advance and regular rates, say conference organizers. Medtrade Spring is scheduled for March 27-20 at the Mandalay Bay Convention Center. SmartSaver rates are in effect until Dec. 10. To register: https://registration.experientevent.com/showMTH182?flow=attendee