VNAA Strongly Objects to ALJ Delays, Calls for Immediate Federal Action
Tuesday, February 11, 2014
by: VNAA Policy Team

Section: Public Policy and Advocacy

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On Feb. 11, 2014, VNAA sent a letter to Kathleen Sebelius, Secretary, U.S. Department of Health and Human Services (HHS) and Marilyn Tavenner, Administrator of the Centers for Medicare and Medicaid Services (CMS) voicing VNAA’s strong objection to significant delays in the assignment of provider requests for Administrative Law Judge (ALJ) hearings. VNAA called for an immediate action to resolve this issue.

In addition to the letter, VNAA will participate in a Feb. 12 OMHA Appellant Forum in Washington, D.C. that will provide updates to OMHA appellants on a number of initiatives designed to mitigate a growing backlog in the processing of Medicare appeals.

Section 42 USC 1395ff(d)(1) [Social Security Act § 1869(d)(1)] requires the ALJs to conduct a hearing and issue a decision within 90 days of receipt of a request for hearing and outlines time requirements for the other levels of appeal. Delays of at least two years in granting an ALJ hearing for an appealed claim are a direct violation of this statute.

VNAA offers solutions to mitigate the detrimental impact of federal mismanagement on home health and hospice agencies as follows:

  • Suspension of RAC audits until all levels of the determination and appeals process catch up with their current workloads. This would allow time for claims with audits in progress to work their way through the appeals process and minimize the number of claims added to the existing backlog.
  • Postponement of recoupment of disputed funds until after the agency receives an ALJ determination.
  • Enforcement of the RACs’ deadline to issue a decision on a claim by denying a RAC its contingency fee for any claim beyond deadline.
  • Lowering of the RAC additional document request (ADR) limit to decrease the volume of claims that can potentially end up in the appeals system.
  • Enforcement of statutory timeframes for appeals determinations. If an appeal is not heard within the required time period, a default judgment will find in favor of the provider.
  • Immediate changes to systemic issues with the RAC audits process that lead to avoidable claim denials and appeals including a mechanism for reversal of erroneous denials outside the appeals process.
  • Analysis of claims overturned at the ALJ level of appeal to determine patterns of erroneous decision making by RAC auditors.

Copies of VNAA’s letter were also sent to the chairs and ranking members of the Senate Finance, House Ways and Means and Energy and Commerce Committees.

VNAA will provide updates based on the response to the letter and OMHA’s Feb. 12 Medicare Appellant Forum.

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