Group Representing RAC’s Blasts ALJ Delays, Seeks Reform

Add the Medicare contractors lobby to the growing chorus of stakeholders calling for reforms to the current Medicare appeals process, specifically the recently announced delays to Administrative Law Judge (ALJ) level appeals. The American Coalition for Healthcare Claims Integrity (ACHCI), which represents Medicare contractors, including Recovery Audit Contractors (RAC), called for sweeping changes to the current appeals process, but offered few specific policy proposals.

In a letter to Congressman Sam Graves (R-MO), who is the primary sponsor of HR 1250, The Medicare Audit Improvement Act, targeted to hospital audit concerns, ACHCI discussed their concerns with the current appeals system. Citing the ALJ backlog and suspension of assigning hearing dates, ACHCI says the ALJ system is in dire need of reform, claiming the delays are undermining the audit process and audit contractors, while subverting Medicare policy. 

Many Medicare providers impacted by audits, including independent orthotists and prosthetists, would argue just the opposite. The RAC auditors are undermining the audit process and subverting Medicare policy by abusing their considerable power to identify and recoup potential overpayments by focusing on clerical, rather than clinical errors. As I’ve written previously, the shortcomings of the current audit process are driving small, independent O&P providers out of business.

The American Hospital Association (AHA) and many other medical professional groups, including OPGA, have come out full speed ahead after the recent memo from Chief ALJ Nancy Griswold, arguing that a temporary suspension in assigning ALJ appeal dates warrants a temporary suspension in performing audits until an adequate appeals process can be identified. At a minimum, recoupments should not be being made while a provider is awaiting an assignment date from ALJ appeal.

A recent appropriations bill which passed both the House and Senate and was signed into law by President Obama included language that seeks to bring more transparency to the current audit program, but does nothing to address the underlying problem. Independent O&P’s cannot adequately serve our patients while dealing with the duration of the current audit appeals system. CMS is allowed to begin recouping dollars associated with appealed claims while the claim is still in dispute (awaiting the 24 month delay for an ALJ hearing). Independent providers simply cannot withstand the cashflow pressures, nor the added expense of navigating the convoluted and timely appeals process.

The issue of audits is becoming a hot topic in Congress and independent orthotists and prosthetists must continue to apply pressure and ensure our members of congress are aware of our objections to the current process and what we see as potential solutions.

Contact your member of congress today about the egregious tactics being used by audit contractors to void claims for Medicare beneficiaries. OPGA President Dennis Clark recently sent a letter to congress detailing our objections to the current appeals process.

The Full text of the OMHA letter can be found here. Send this letter to your member of congress to explain the incredible backlog and suspension of certain hearing dates.

Need help contacting congress? Email me @ and I will help facilitate your connections.

This entry was posted in Orthotics and Prosthetics, Patient, Prosthetist, re provider and tagged , , , , , . Bookmark the permalink.

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