To be continued ...

When we included a Q&A with Josh Britten in our HME Newswire in February, I wasn’t surprised it resonated with readers.

Britten, CEO of BritKare Home Medical, shared his battle to get back nearly $650,000 in denied Medicare claims – a battle that took him six years and more than $100,000 in legal and consultant fees.

One provider responded to the story on Twitter by writing: “When you incentivize claims denial as a means of revenue generation you will find reasons to deny claims. Kudos to Mr. Britten for sticking it out and pouring one out for the companies that can’t afford to fight.”

Another, in response to one of Britten’s claims being denied due to a zip code with one wrong digit: “The zip code anecdote is emblematic of a horribly broken system.”

But there’s more to the story.

Wayne van Halem, who helped Britten with his case, also helped another provider who recently received a positive decision from the ALJ. This time, more than $10 million was tied up in the appeals process.   

I’ll let Wayne take it from here:

“Our client had a team of attorneys, in addition to our team, working on this for the last seven years. There were 66 claims in question. On the day of the hearing, the judge cut the hearing short and asked us to submit a written post-hearing brief outlining our arguments. It was a lot of work, but we pulled together a 138-page document outlining arguments for every claim. In the end, the judge ruled that the extrapolation was valid, but when it came to the claims, he overturned 63 of the 66 claims. With an error rate that low, the contractor will not re-extrapolate the overpayment and, in the end, our client will end up refunding three claims with an overpayment below $1,000. From $10 million to less than $1000.  They received a check from Medicare for over $12 million because of the interest.”

These years-long battles with the Medicare appeals process have been the status quo due to years-long backlogs at the ALJ.

The good news, as van Halem has shared, is that the ALJ should be caught up on the backlog sometime this summer. 

The bad news, as Britten also shared, is that managed care companies, unlike Medicare, don’t have a system in place for appealing denied claims.

“He’s soooo correct,” wrote one provider on Twitter in response to Britten’s concerns. “The MA and MCO plans are historically horrible at communicating denial and audit procedures post-claim submission.”

It’s one thing to have a broken system; it’s another to have no system at all.

“Looking forward, it’s what DME stakeholders need to be looking into,” Britten said.