The National Association for the Advancement of Orthotics and Prosthetics (NAAOP) released a webcast in which NAAOP General Counsel Peter Thomas, JD, discussed the Office of Medicare Hearings and Appeals (OMHA) forum held October 29 about the Administrative Law Judge (ALJ) appeals backlog; the ALJ hearing is the third level of the Medicare claim appeals process. This forum, led by Chief ALJ Nancy Griswold and other U.S. Department of Health & Human Services (HHS) officials, was the first opportunity for the public to receive an update on the ALJ backlog and to pose questions to OMHA since the February 12 forum.
A summary of the webcast, as provided by NAAOP, follows:
There were no major announcements that are expected to break the logjam in ALJ appeals, only modest developments that are not expected to significantly accelerate access to a hearing on Medicare O&P claims denials.
OMHA reported that it continues to address the backlog by pursuing some of its pilot programs, including the exploration of a method for statistical sampling of certain cases to extend a particular holding to multiple similar cases. This process is being tested with Part B claims and does offer at least some promise for O&P providers in the future. OMHA devoted about 18 percent of its increased budget this year to hire seven new ALJ teams based in Kansas City, Missouri, that are expected to decide 1,000 cases each, per year. This is a far cry from the crushing demand as requests for ALJ hearings continue to pour in, even while the Recovery Audit Contractors (RACs) are not fully functioning. OMHA also stated that it is standardizing its business and documentation practices, which, it believes, will make the ALJ teams more efficient in processing appeals.
With respect to the settlement offer available to hospitals, where hospitals had until the end of October to accept 68 percent of the reimbursement amount for short-stay claims, OMHA stated that it expects the settlement of about 110,000 cases, which would remove these cases from the backlog and make way for other appeals to progress more rapidly than currently expected. Given the fact that Griswold has estimated the backlog at nearly one million cases by the end of this year, this is a relatively and unexpectedly small impact.
OMHA also announced that it is holding internal discussions about additional opportunities for providers to discuss denials at lower levels of appeal before these cases get to the ALJ level of review, but that would not do anything to reduce the current backlog of cases. Most of these steps (except the hospital settlement) are not expected to affect the backlog to any meaningful extent. Most forum participants agreed that the only way to curtail a future backlog in cases is to dramatically reform the RAC program.
Congressional staff continue to consider reforms to the audit and appeals process even on the eve of the 2014 elections. Current intelligence from Capitol Hill suggests that the expected “lame duck” session will be short and not particularly productive. However, there is still a chance that additional legislation that impacts O&P audits and appeals could be introduced before Congress adjourns, setting the stage for legislative activity in the new Congress.
The webcast is posted on the NAAOP website, shared with members via e-mail, and made available through the NAAOP page on Facebook.