Major Medicare Audit and Appeals Developments

Significant developments related to Medicare audits and appeals occurred this spring that impact all providers of Medicare services, including O&P practitioners and suppliers. Three issues that most directly involved O&P were: the announcement—and subsequent rescission, after coordinated objection from the O&P profession—of a Recovery Auditor Contractor (RAC) audit on Healthcare Common Procedure Coding System (HCPCS) code L-5845, an adjustable stance flexion feature used with a variety of single axis knee codes; two federal circuit courts held oral arguments in cases challenging the massive backlog of claim appeals at the Administrative Law Judge (ALJ) level and the delays by the Office of Medicare Hearings and Appeals (OMHA) in rendering Medicare claim denial decisions; and, finally, the U.S. Senate edged closer to reintroducing the Audit & Appeals Fairness, Integrity, and Reforms in Medicare (AFIRM) Act (formerly S. 2368 in the 114th Congress). The president’s budget request for fiscal year (FY) 2018 essentially endorses most of the provisions of this act, including a massive increase in funding to hire more ALJs.