Appealing RAC decision? Wait in line

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Hospitals and physicians challenging auditor decisions on Medicare reimbursement may have a long wait to have their day in court. The federal office that handles appeals is warning providers that it has temporarily suspended assignment of most new requests in an effort to whittle down its 16-month wait time.

The Office of Medicare Hearings and Appeals (OMHA) will hold a one-day Medicare Appellant Forum Feb. 12 to unveil initiatives designed to stem the rising tide in appeals from providers and beneficiaries. Hospitals and physicians who disagree with Medicare Recovery Audit Contractor (RAC) payment denials can appeal to the OMHA, which is the third level of administrative review in the process.

According to the American Hospital Association, 71 percent of hospitals that participated in its third quarter 2013 RACTrac survey reported they still had appeals claims pending.

The OMHA sent letters at the end of 2013 to hospitals and healthcare systems with a high number of pending reviews informing them that it had suspended assignments of most new cases. The move was designed "to allow OMHA to adjudicate appeals involving almost 357,000 claims for Medicare services and entitlements already assigned to its 65 Administrative Law judges."

The office added that its workload had grown 184 percent between 2010 and 2013 while resources under sequestration had diminished. The backlog had reached 460,000 claims for services and entitlement, up from 92,000 two years ago.

It planned to continue assigning and processing beneficiary requests and would lift the suspension once its workload lightens. “However, with the current backlog we do not expect general assignments to resume for at least 24 months and we expect post-assignment hearing wait times will continue to exceed six months,” it wrote.

The February forum will include information on steps appellants can take to facilitate the appeals process.

For tips on avoiding this administrative quagmire, read “Remorse Code: Mistakes that Prompt an Audit” in Cardiovascular Business.