As a provider of services to Medicare patients, you normally submit a claim for payment of service to a Medicare Administrative Contractor [MAC] and expect to be paid within a reasonable timeframe. You are a business and have expenses that need to be paid in order for you to remain open. Any disruption in the flow of claim payments to you can result in severe hardship to you and your practice.
If the MAC denies your claim or claims, you can request a redetermination of the denial of payment. The MAC has 60 days to make a decision on the redetermination.
If the MAC continues to refuse to pay the claim or claims, you can then appeal the refusal to a Qualified Independent Contractor [QIC] and request a reconsideration of the MAC’s decision. The QIC has to complete its review within 60 days.
If your claim continues to be denied, you can request a hearing before an Administrative Law Judge [ALJ]. The Social Security Act requires that the ALJ “render a decision … not later than the end of the 90-day period beginning on the date a request for hearing has been timely filed.”
The process, from redetermination through the ALJ hearing and decision, should easily take less than 9 months. This is a long time to determine if a provider is being unduly deprived of funds. Actually, it is too long when one considers its impact on a practice’s cashflow.
On December 24, 2013, the Chief ALJ notified Medicare provider appellants that as of July 15, 2013, she had “temporarily suspended the assignment of most new requests” for ALJ hearings. She anticipated this would result in about a 2.5 year delay before a request for hearing could be heard. This delay was announced despite statutory and regulatory mandates to the contrary. The Obama administration has arbitrarily decided that it can delay a hearing that relates to provider claim payments for 2.5 years. The Obama administration justifies its actions by saying that its ALJs are overworked because their caseloads have increased significantly.
You have to ask yourself why has the number of appeals increased? The reason is simple: the number of provider claims denied or challenged has increased. CMS knew this would happen but did not prepare for it. CMS had contracted with private Recovery Audit Contractors [RAC] to audit provider claims. RACs are paid by contingency fee. They receive a cut of payments they recover. So, it makes sense that challenges of payments would increase. Common sense would have directed that the Obama administration prepare itself for this eventuality. It did not. And now, providers must endure significant delays in resolving payment challenges.
The Obama administration and Congress, both aware of the negative impact this has upon providers, have not come up with a solution. As of December 2014, attempts to make the Courts force the administration to adhere to statutory and regulatory mandates has fallen upon deaf judicial ears. No one in Government seems to be interested in the provider’s well being.
When will providers come to the realization that it is Government that needs them, not the other way around. The Government cannot provide healthcare to the Nation without providers. It seems that it may be time for providers to consider organizing into a more tightly knit group. Nothing else seems to be working.