Health Information Management

AHA urges CMS to address RA-appeals delay

HIM-HIPAA Insider, January 27, 2014

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by Jaclyn Fitzgerald, Associate Editor
In a recent letter, the American Hospital Association (AHA) urged CMS to work with the Office of Medicare Hearings and Appeals (OMHA) to resolve the 24-month suspension of most new requests for Administrative Law Judge (ALJ) hearings. The AHA attributed the temporary suspension to inappropriate denials by Medicare Recovery Auditors.
The AHA stated that the delay is unacceptable and violates the Medicare statute requiring ALJs to make a determination within 90-days of receiving a hearing request. In addition to working with OMHA on a resolution, the AHA recommended that CMS take the following actions:
  • Suspend RA audits until those involved in the determination and appeals process catch up with their workload
  • Hold off on recouping disputed funds until hospitals receive an ALJ determination
  • Enforce statutory timeframes for appeals determinations by entering a default judgment in favor of the provider in instances when the appeal has not been heard within the required timeframe
  • Address systemic issues with RAs that cause avoidable denials and appeals, and provide a means of reversing erroneous denials outside of the appeals process
  • Lower the additional documentation requirement limit to decrease the number of claims that could be appealed
  • Enforce the RA deadline for issuing a decision by denying RAs their contingency fee for claims that miss the deadline

In a separate letter,
the AHA urged Congress to encourage CMS to adopt the RA reforms outlined in the Medicare Audit Improvement Act of 2013. In its letter, the AHA also requested that Congress work with CMS to adopt a policy change that would only permit CMS to recoup disputed funds after receipt of an ALJ determination.

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