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 Medicare Appeals Backlog A ‘Clear And Present Danger’ To Senior Care

​Long term and post-acute care providers are expressing concern about the monstrous backlog of Medicare appeals at the Department of Health and Human Services (HHS).

HHS says it has been inundated by appeals to administrative law judges from a wide array of health care professionals and has suspended new appeals for at least two years, since July 2013, while the agency hacks away at the dense caseload.

But Vetter Health Services President Glenn Van Ekeren says that neither his company nor the residents who depend upon it can wait that long to find out whether their long term or rehabilitative care is going to be covered.

“That could potentially hamper our ability to continue delivering quality services to  seniors whose care they and their families entrusted to us,” Van Ekeren says.

Van Ekeren is a board member of the American Health Care Association (AHCA), which is challenging HHS to rethink its backlog—and the policies that underlie it. The delays, Van Ekeren says, are “a clear and present danger.”

HHS, for its part, says that its 65 administrative judges are underwater after a tsunami of appeals from providers. In January 2012, HHS saw an average of 1,250 cases filed; by December 2013, there were more than 15,000 new cases every week.

There are now more than 460,000 open appeals waiting for resolution, and officials at HHS say they simply can’t keep up. The agency stopped assigning new hearings to the administrative judges as of last July. HHS promises that it is still keeping up with direct appeals from Medicare beneficiaries.

To long term care advocates, Congress could spare itself the administrative nightmare it has created by revisiting its policies, such as its requirements of pre-payment audits that many providers say merely gums up care.

Whatever happens in the policy battles, long term and post-acute care advocates and other providers have made a seemingly strange friend in the struggle against the appeals logjam: the auditors themselves.

“The nation is currently facing the systematic dismantling of health care integrity programs that fight an epidemic of wasteful spending among Medicare providers,” the American Coalition for Healthcare Claims Integrity said in an open letter to Congress last week.

Perhaps hoping to calm things down, HHS has scheduled a forum for Feb. 12 to discuss the appeals cases and to try to iron out ongoing problems in the system.

For AHCA board member Van Ekeren, though, the status quo won’t answer.

“One of two things needs to occur in the coming weeks and months,” he says. “Either the volume of these cases needs to be reduced, or HHS needs to increase the resources necessary to clear the backlog.”

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