Coalition seeks fix to 'feeding frenzy' of audits

WASHINGTON - A new coalition led by a long-time industry healthcare attorney and former White House and Health and Human Services (HHS) advisers has made audit relief its singular priority.

The Medicare Appeals Due Process Coalition will work on behalf of HME providers to reform the appeals process for audited and denied claims.

“It's important to get different types of providers together and raise their voice with CMS and Congress to see if we can get this fixed,” said Jennifer Summa, a senior policy adviser for Baker Donelson and a former senior adviser to CMS Deputy and Acting Administrator Leslie Norwalk. “You need to have numbers to be heard.”

Summa is joined by Stephen Azia, counsel at Baker Donelson; Lance Leggitt, chairman of the firm's Health Care Government Affairs Practice Group and a former senior health policy advisor to George W. Bush; and Nancy Johnson, a former member of Congress and chairwoman of the Ways and Means Health Subcommittee.

The coalition has two goals. The first: Work with CMS to find a way to expedite the appeals process. By law, an ALJ must conduct a hearing within 90 days, but the Office of Medicare Hearings and Appeals (OMHA) announced recently that it would defer assignment to the ALJs up to 28 months.

“There has become a feeding frenzy in terms of audits and denials, and it has jammed the system,” said Leggitt. “CMS is letting the appeals system determine what's a valid claim and what's fraud, and because a small percentage is fraud, it's not the most efficient way of doing it. The process needs to be more qualitative.”

The second goal: Work with Congress to get statutory language enacted that would prevent CMS from making any recoupments until a provider has gone through the ALJ level—at minimum. That's key because the first two levels of appeals are more administrative and don't involve a hearing, and because 56% of the time the ALJ reverses the decision of the previous level.

“No provider should have to wait two years for an appeal, while money is being taken away,” Azia said. “We've seen, because of extrapolation, where 30, 40, or 50 claims representing $20,000 become $2.5 million. It really becomes threatening to the existence of any provider.”

Since Leggitt, along with Summa, was part of a small group of advisors that oversaw the establishment of OMHA, he knows how broken the system has become.

“Congress has been very reactive when engaged on this,” he said. “We need to say, 'Look, you made changes a decade ago and the problems are getting worse.'”