RAC Monitor’s Monitor Monday Webcast January 27, 2014

Play webcast
Chuck’s intro of Drew – 15:30
Drew starts – 15:34
Drew ends – 19:45
Chuck thank you ends – 19:50

Andrew Wachler, Esq., Wachler & Associates, P.C. speaking:

Good morning, Chuck.

I’m speaking briefly on the Appellant Forum. Again, I think this is a very important opportunity to galvanize both provider and beneficiary support to accomplish a fair and meaningful appeals process. Please send any thoughts you have to Chuck Buck at his email at cbuck@racmonitor.com.

We currently have a wait of 2-4 years with a statutory requirement of 90 days. So, the law mandates 90 ds. There’s no easy fix because of the simple math of the volume that we have. When we look at the stakeholders here, the RACs and CMS get their $5 billion to split, OMHA gets blamed for the delays although they’ve gotten no additional resources and providers take the brunt by funding these delays through the withhold process and through PPUR. It is important to remember that when we had this reform legislation initially, it was because we were having significant delays on both the Part B Fair Hearing side and the Part A Social Security Administration appeals. We actually had a case that took 8 years to get through the process. When we were done, the government paid our client $6 million dollars, so it was worth the wait, but that’s not the point. We need a prompt appeals process. That was the legislative intent.

So we have this forum and the purpose of the forum, as set forth in the Federal Register, is to solicit input from the appellant community to help OMHA evaluate its policies and procedures to achieve meaningful backlog reduction strategies and process efficiencies while remaining compliant with the applicable legal authorities. The majority of the forum is going to be presentations by OMHA with an opportunity to input.

Why is this happening now? I really believe that OMHA as an agency needs the support, needs additional resources. This is an opportunity for hospitals and other providers to engage in political action coalesce and develop really an organization and galvanize support. Before this forum was set forth, about a week before, I spoke with Chief Administrative Law Judge Nancy Griswold, and I told her that I thought what was missing was a lack of consistency and input from the hospital community. She said in response that there was going to be that opportunity and it’s coming up.

So, what are some of the solutions? It’s not easy, but we have to push for them.

  • One, I think there should be a committee and it should stand from some basic principles. I think most of these are supported by the American Hospital Association.
  • No withholds or prepayment review without acceptable fair and reasonable appeals process.
  • Increased resources for OMHA.
  • Legally enforce the current statute. If you miss your timeframes from a day, you’re out. They’re not going to find good cause. But CMS cannot comply with its guidelines.
  • Alternative dispute resolution.
  • Expand the discussion period. Medicare cases do not have the ability to settle. Set a forum in which you can resolve these cases.
  • Mediation, arbitration or accelerate cases to federal court.
  • More effectively consolidating cases.
  • Lower ADR limits until this is caught up.
  • Create a consistency of ruling among ALJs in terms of procedural matters.

With that, Chuck, I’m out of time. Back to you.

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