Chief ALJ Details 460k Appeals Backlog, Suspension of Hearings

A recently obtained memorandum from the Office of Medicare Hearings and Appeals (OMHA) Chief Administrative Law Judge Nancy Griswold to Medicare providers awaiting multiple Administrative Law Judge appeal hearings details the exponential growth in appeals to Medicare audits. The letter provides the most up-to-date appeals data that has been released by The Centers for Medicare and Medicaid Services (CMS) to date and includes some particularly damning statistics and statements about the appeals system.

Judge Griswold  states that from 2010-2013, OMHA’s claims workload grew by 184%. In just two years, the backlog of appealed claims has risen from 92,000 to 460,000, causing OMHA to suspend the assignment of hearing dates effective July 15, 2013.Citing a lack of additional resources allocated to handle the dramatic increase in appeals volume, Griswold states that in January 2012, their office averaged 1,250 appeals a week, in December 2013, they averaged 15,000. Average wait time now exceeds 16 months and with the current backlog, OMHA does not expect to begin assigning new ALJ hearing dates for atleast 24 months. As a point of reference, there are a total of 65 Administrative Law Judges nationwide.

How can this be possible? How can CMS audit claims, require providers to respond and in most cases repay the disputed monetary value associated with the claim without offering an adequate appeals process? The lack of due process is truly appalling.

Additionally, according to current rules governing Medicare audit programs and appeals, after a provider has exhausted the first two levels of appeal (reconsideration and redetermination), the provider has until 31 days following their appeal to the ALJ to pay the balance of the audited claim. Providers can choose to pay the amount in full, enter into a high-interest payment plan with The Centers for Medicare and Medicaid Services (CMS), or CMS will begin garnishing current claims reimbursement until the debt is satisfied. Considering the two-year delay in receiving an ALJ hearing date, how can CMS continue to hold providers to this arbitrary and capricious date for payment while simultaneously suspending the appeals process?

OPGA and others in the O&P profession have been arguing that recoupments should not be allowed on disputed audits until after full adjudication of the appeals process. The current audit appeals system eliminates due process for those seeking appeal. Any and all audits initiated after the suspension of assignment of new appeal dates should be immediately dismissed until an adequate appeals process can be determined and the incredible backlog of appeals are processed.

In response to the letter from Chief Administrative Law Judge Nancy Griswold, OPGA President Dennis Clark sent a letter detailing the concerns of independent orthotic and prosthetic providers with the current backlog of appeals and lack of due process moving forward. A copy of the letter can be found here.

Contact OPGA to see how you can help get in contact with your elected officials and get them to help pressure CMS into delaying recoupments until after full adjudication of the appeals process.

Full text of the OMHA letter can be found here.

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5 Responses to Chief ALJ Details 460k Appeals Backlog, Suspension of Hearings

  1. Jan Saunders says:

    Ryan So then what happens? Jan

    • ryanball1 says:

      They have yet to announce any potential solutions. This 460k backlog likely includes all providers, hospitals, physicians, DME, OP, etc. Perhaps this is what finally unites providers to put an end to these egregious practices and delays. There was some language in the SFC committee SGR markup pertaining to audits, our best bet is to try and expand on that to get legislative relief. Also working with SBA on similar line of attack.

  2. Pingback: Group Representing RAC’s Blasts ALJ Delays, Seeks Reform | OPGA Blog

  3. Pingback: OPGA to Attend Medicare Audits Hearings & Appeals Forum, Seeks Stories | OPGA Blog

  4. Pingback: CMS to Temporarily Halt RAC Audits to Transition to New Contracts | OPGA Blog

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