Orthotic & Prosthetic Group of America (OPGA), Waterloo, Iowa, and the American Hospital Association (AHA) have taken independent actions to address the consequences the two-year suspension of Administrative Law Judge (ALJ) hearings for an appealed claim and the 460,000-case backlog are having on their respective professions. An ALJ hearing is the third level of appeal available to providers who are appealing Recovery Audit Contractor (RAC) claim audits.
According to a letter OPGA obtained that is being sent by Chief ALJ Nancy J. Griswold with the U.S. Department of Health and Human Services Office of Medicare Hearings and Appeals (OMHA) to providers, due to a backlog of claims pending an ALJ hearing as well as cases pending assignment, OMHA does “not expect general assignment to resume for at least 24 months,” and the wait time for post-assignment hearings “will continue to exceed six months.” The letter states there has been a 184 percent increase in claims submitted for ALJ review from 2010-2013, and OMHA’s average wait time for a hearing before an ALJ has risen to 16 months. That time is expected to continue to increase as the backlog grows.
OPGA President Dennis Clark, CPO, addressed a letter to Senator Charles Grassley (R-IA) outlining his concern, questioning the legality of the lack of due process facing providers, and requesting relief for the O&P profession. “How can audit contractors continue to audit claims if there is no adequate appeals process in place to offer providers?” he asked.
In a separate action, the AHA wrote a letter to Marilyn Tavenner, the administrator of the Centers for Medicare & Medicaid Services (CMS) that expressed its concern over this same matter and offered recommendations to temper what it says are the negative effects of RAC denials. “Delays of at least two years in granting an ALJ hearing for an appealed claim are not only unacceptable, they are a direct violation of Medicare statute that requires ALJs to issue a decision within 90 days of receiving the request for hearing,” the letter stated.
