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DME Suppliers, Get More Information on Your Medicare Appeals

A new Office of Medicare Hearings and Appeals (OMHA) website offers intel on reimbursement appeal status, but does little to speed up the appeal process or eliminate the current backlog. It does, however, provide useful documentation, and DME suppliers should consider the impact of the delay on Section 935 interest.

OMHA just unveiled a new website to enable suppliers to monitor their ALJ appeals. The ALJ Appeals Information System (AAIS) website allows users to check the status of filed Medicare reimbursement appeals. OMHA also created a listserv to provide updates to suppliers regarding the Medicare appeals process, special initiatives, pilot programs, website updates, and other information pertinent to appeals. Users can register for the listserv here. The AAIS website is another effort to reform the criticized Medicare reimbursement appeals process, and comes on the heels of two recent programs designed to process ALJ hearings more efficiently and clear the current backlog: the Part B Settlement Conference Facilitation Pilot Program and the Statistical Sampling Initiative.

Offers Suppliers Proof of Filing and Status Documentation

The AAIS website can offer suppliers official appeal status data which can be useful to facilitate other actions. For example, suppliers facing recoupment and referrals to the Treasury Department for collection have had difficulty obtaining official proof from OMHA that the ALJ appeal is on file (oftentimes resorting to the delivery confirmation as proof). The status report from the new website can be used to provide clear proof the appeal was filed and received, and can then be used to reverse an involuntary collection action taken by the Treasury Department.

The AAIS website offers suppliers the following status information:

  • Received – OMHA has received the supplier’s appeal, but it has not been assigned to an ALJ for review.

  • Assigned – The appeal has been assigned to an ALJ for review, and the name of the ALJ will also be provided online.

  • Deliberation – The decision for this appeal is being developed by the ALJ indicated online.

  • Decided – This appeal has been decided. This includes appeals that have been dismissed or escalated, or decided (favorable, partially favorable, or unfavorable). Despite the website’s weekly updates, supplier appeal status will not be available until the case is uploaded into OMHA’s tracking system, a process that takes least 4 months from the date the supplier files the appeal, according to OMHA. (Beneficiary-filed appeals receive priority and will be available online within a week of filing.) In addition, the website will not offer status on appeals that were decided or otherwise closed for 180 days, or appeals for which the supplier has requested settlement through CMS.

Won’t Speed Up Appeal Process

Despite the website’s weekly updates, supplier appeal status will not be available until the case is uploaded into OMHA’s tracking system, a process that takes least 4 months from the date the supplier files the appeal, according to OMHA. (Beneficiary-filed appeals receive priority and will be available online within a week of filing.) In addition, the website will not offer status on appeals that were decided or otherwise closed for 180 days, or appeals for which the supplier has requested settlement through CMS.

Moreover, there is no expectation the system will speed up the appeals process (though ideally OMHA staff can devote more time to processing appeals instead of fielding appeal status queries). Appeals will still need to be assigned to an ALJ and scheduled before a decision is issued.

Consider Appeal Delay’s Impact on Section 935 Interest

As of December 2014, OMHA has a backlog of nearly 1 million appeals, and the average supplier waits approximately two years for a decision to be issued. This delay has created significant strategic decision making opportunities for suppliers with regard to Section 935 interest calculations, particularly since over 42% of appealed claims received fully favorable ALJ rulings last year. Section 935 allows a successful supplier to receive interest accrued during the appeal waiting period if CMS involuntarily recoups the alleged overpayment on appeal.

Despite the ALJ backlog, the AAIS does offer suppliers another element of transparency. While the ALJ appeals process can be aggravating and inefficient, suppliers hope OMHA continues to reduce the appeal backlog and meet its legislatively mandated processing deadlines.

© 2020 Foley & Lardner LLPNational Law Review, Volume V, Number 70

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About this Author

Nathaniel Lacktman, Health Care Attorney, Foley and Lardner Law Firm
Partner

Nathaniel (Nate) Lacktman is a partner and health care lawyer with Foley & Lardner LLP, and a Certified Compliance & Ethics Professional (CCEP). His practice focuses on health care compliance, counseling, enforcement and litigation, as well as telemedicine and telehealth. Mr. Lacktman is a member of the firm’s Health Care Industry Team which was named “Law Firm of the Year — Health Care Law” for three of the past four years on the U.S. News – Best Lawyers® “Best Law Firms” list. 

813-225-4127
Richard Werblow, Health Care Attorney, Foley Law Firm
Associate

Richard C. Werblow is an associate and health care business lawyer with Foley & Lardner LLP. His practice includes providing analysis and interpretations on Medicare guidelines, CMS policy and medical industry standards and trends. He is experienced in pre-trial litigation matters, mediations and depositions as well as issuing Medicare Parts, IRMAA, entitlement, and recovery audit contractor appeal decisions. Mr. Werblow is a member of the firm’s Health Care Industry Team.

305.482.8416