Senate committee prioritizes audit, appeals reform

WASHINGTON - Forcing Medicare to better coordinate audits and improve the appeals process is one of the top priorities of the Senate Finance Committee this year, Kimberly Brandt told attendees at the AAHomecare Washington Legislative Conference on Wednesday.

The committee plans to conduct a hearing for its AFIRM Act this summer, setting the stage for the bill to be re-introduced later this year, said Brandt, chief healthcare investigative counsel for the committee.

“We hope to come out with finalized language no later than the fall,” she said.

But the challenge this year, as it was in 2015, when the bill was first introduced, is cost. The Congressional Budget Office gave the Audit & Appeals Fairness, Integrity and Reforms in Medicare Act of 2015 a $1.4 billion price tag.

Despite that challenge, the committee remains dedicated to reform—the problem is too big to ignore, Brandt says. The backlog at the administrative law judge level, the third level of appeal, is more than 700,000 cases deep, she pointed out, meaning if you submitted a case today, it would take more than 830 days to get a hearing.

“That's unacceptably long,” she said. “The ALJ can't solve cases fast enough.”

The committee also got reaffirmation recently, when a judge overseeing litigation related to audits and appeals between the Department of Health and Human Services and the American Hospital Association said the AFIRM Act would go a long way toward solving issues, Brandt said.

“We were pleasantly surprised by that,” she said.

While the specifics of the bill will likely be reworked this year, the overall goal is holding Medicare accountable for how it organizes and conducts audits, and oversees its auditors, Brandt said.

“There aren't even consistent standards that auditors are held to,” she said.

While the committee does its work, the industry partnered with Rep. Marsha Blackburn, R-Tenn., in May to introduce a bill that would require prior authorization for certain high-cost DME. A provision in the bill would exempt approved claims from subsequent pre- and post-payments audits.

“Prior authorizations are the way to go, in terms of a long-term fix,” said Jay Witter, senior director of government affairs for AAHomecare.