The ALJ Appellate Forum on Wednesday, February 12th will be chock full of information that all outpatient therapy providers need to know. If you have provided therapy over the $3700 caps (threshold) there is 100% RAC review of your claim(s). Technically this is the OMHA Medicare Appellate Forum, but the provider industry has been quick to label it the ALJ Appellate Forum due to the significant backlog of appeals at the ALJ level, in large part because most providers involved in the appeals process as a result of RAC denials feel they have their best shot at the ALJ, 3rd level of appeals.
In a nutshell due to the significant increase in the number of appeals being filed (in large part due to the RAC program) and reaching the ALJ level, Chief Judge Nancy Griswold issued a letter in late December to those having a “significant number of appeals pending OMHA”. The letter indicates that due to the current backlog the OMHA does not expect general assignment to resume for at least 24 months and that they further expect post-assignment hearing wait times “will continue to exceed 6 months”.
The statistics are staggering, but the solution to clear the backlog is creating significant financial burden for large providers and small providers alike. The letter announces the OMHA Appellate Forum, which, according to Judge Griswold, ” is to provide further information to OMHA appellants and providers on a number of initiatives underway and to provide information on measures we can take to make the appeals process work more efficiently”.
ALJ Appellate Forum – What Therapy Providers Need to Know
Therapy over the $3700 therapy caps (thresholds) is 100% subject to mandatory manual medical review. CMS has turned this process over to the Recovery Auditors, and it is in effect through 3/31/2014 due to the SGR Legislation (the future is still uncertain, pending congressional action). Some RAC rules apply, most do not. Those in the 11 prepayment review states, wait to get their reimbursement pending a 10 day review and approval of the therapy provided over the $3700 caps by the RACs. In the other 39 states, therapy providers are paid, then subject to mandatory post-payment review by the RACs. The manual medical review system has not gone very well from the provider perspective, and it is likely that the RACs don’t like it either. Most importantly providers that find their claims are denied have the right to appeal, and likely have started the process on 2013 claims, particularly in the pre-payment review states. However in the post-payment review states many providers are getting bulk ADR request spanning several months (remember the RAC rule of ADR limits is not in effect for therapy MMR claims), and the prospect of getting their money recouped in the appeals process, and having it held for over 2 1/2 years might prove to cripple a small therapy practice.
Most therapy providers have never had their charts reviewed by a Medicare contractor, and now find a rude awakening when presenting records for RAC review. If you are a provider in this situation, this likely be the first time that you use the Medicare appeals process. The time you will spend learning about the process, filling out the forms, and preparing your case, may even cost you more than the reimbursement you will receive.
Therapy providers need to assess beneficiary utilization, carefully track the cap and the threshold, and ensure from the evaluation and first progress note moving forward that therapy is medically necessary, and more importantly that the medical record substantially supports evidence of medical necessity sequenced through the plan of care and subsequent progress reports. If you are going to potentially have to wait 2 1/2 years for a hearing on a denied claim, it is essential that the medical necessity of skilled care be effectively demonstrated and documented.
While the agenda for the ALJ Appellate Forum has been posted, the “live” seats and the “remote” seats are no longer available. I will be reporting live with the RAC Monitor team from the Appellate Forum. RAC Monitor regular panelists Drew Wachler and Paul Spencer will be live onsite in Washington DC at the OMHA Appellate Forum. Publisher Chuck Buck and I will be remote at our “anchor desk”. We will have two live broadcasts from the forum (approved by HHS) with reports from Drew Wachler and Paul Spencer. There will be a special edition preview of the OMHA Appellate Forum on Monitor Monday, February 10, 2014. We honored to have Chief Judge Nancy Griswold as our special guest. You can register for Monitor Monday, and our special broadcast from the OMHS Appellate Forum here.