On February 12, 2014 VGM attended the ALJ forum in Washington DC.

March 2014 US Rehab Article

On February 12, 2014 VGM attended the ALJ forum in Washington DC.

We “STORMED” the hill well, we “tried” to storm the hill the HILL stormed us and although, a few did get to attend some meetings with legislative staff we did not get to make as many as we wanted to.

The forum was held to inform all concerned about the issues they were having with the huge backlog of ALJ hearings.

The forum was well attended by interested parties from all areas of Medicare including hospitals/ home health but I was proud to see the numbers that VGM brought to the forum. The DME industry was well represented and I know we got the point across that we wanted them to understand.

The VGM/US Rehab members sent me some very good examples of denials that should have never gotten past the first level of appeals. I was able to make contact with a very nice gentleman that listened to my concerns and was very appreciative of the examples we gave him.

I explained in detail the issues that we saw with the lower level of appeals that could be corrected and decrease the amount of claims that had to move on to the ALJ level.

The result, in my opinion, was well worth the trip to attend the forum.

The presentations were very well organized and the speakers were excellent.

Here is what became of our “examples” – the gentleman contacted the C2C contractor with the examples and went over our concerns. I have learned that a manager has them and is reviewing and correcting the issues. We have also been in contact with the C2C solutions through a member of the Jurisdiction D DAC team and they have expressed an interest in working with the DAC to have open communications with the industry to assist with improving the consistency and accuracy of the review process.

CMS has also delayed any further additional RAC audits until the new contract has been assigned in 2014.

They will be giving instructions to the new contractor that they must respond to any requests from a supplier within 3 days from date of phone calls.

a.        We have been asked to assist in gathering documentation with specific issues we see and letting the C2C know if we do not receive timely call backs. I will suggest at this point if you have specific issues please forward them to me peggy.walker@vgm.com  — We need the time and date you called; when and if you received a call back; if you did speak with someone what was the results of that conversation?  As always make sure you get the name or op ID; exactly what was discussed and date and time of the call.

b.     f you have specific items that are truly should not have denied. (something stating that the ______ was not received but it was clearly sent and you have your fax showing number of pages sent with date and time.

c.     Also suggest you make sure you send in a cover sheet that clearly states what is sent with page numbers showing the specific item sent.

If it relates to documentation in physician records or clinical notes that are not matching and not something that can clearly be resolved we would ask that these go through the appeals process.


Some tips from the ALJ forum relating to processing the ALJ easier and quicker.

If you are appealing a Part A or Part B reconsideration issued by a Qualified Independent Contractor (QIC), you may have a right to escalate your request for hearing to the Medicare Appeals Council (MAC), 90 days after you file a complete request for hearing.More information on escalating a request for hearing can be found at 42 C.F.R. sections 405.1104 and 405.1106(b).  When a request for hearing is escalated, the MAC may take any action in accordance with 42 C.F.R. section 405.1108(d), but is not required to conduct a hearing.

Escalating a request for hearing is a two-step process.  See In re General Medicine, P.C. (MAC Sep. 6,2007).  To initiate the process, you must file a written request for escalation with OMHA.  If your request has been assigned to an Administrative Law Judge, please file your request with the Administrative Law Judge’s field office. Please clearly indicate your submission as an escalation request to help us process your request as quickly as possible.  Our field office addresses can be found at http://www.hhs.gov/omha/contacts/offices.html.

If your request has not been assigned to an Administrative Law Judge, please file your request for escalation with:

OMHA — Central Operations

Attn: Escalation Request Mail stop

200 Public Square, Suite 1260

Cleveland, OH 44114

After OMHA receives your initial request for escalation, you may receive a decision, dismissal, remand order, ora Notice on Escalation Request.  However, if you do not hear from us within 10 days (including 5 days for mailing time), you may consider your request escalated and proceed to seek MAC review of the escalated request.  The request for MAC review must:

  1. Contain the required content for a request for review of an escalated case set forth in 42 C.F.R. section 405.1112;
  2. Be sent to both the MAC and the Administrative Law Judge’s OMHA office (or OMHA Central Operations if you sent your request for escalation there); and
  3. Be copied to the other parties to the appeal (for example, the parties who received a copy of the Notice of Reconsideration).

Please note that if you do not request MAC review of an escalated request, the case will remain pending with OMHA and the Administrative Law Judge adjudication process will continue.

  1. Any appeals should use the ALJ request form.
  2. Make sure you do not duplicate requests
  3. Every request needs to be legible (type the information to make sure it is good.)
  4. Do not sent the same information to the ALJ that was already sent to the Q2 contractor
  5. Make sure to include accurate information(HIC numbers etc)
  6. You can ask for an “on the record” hearing and write a brief explaining exactly what the issues are.
  7. You can “bundle” multiple claims to be reviewed with the same judge once you have received notification that a judge has been assigned
  8. OR if you want to bundle multiple claims when you  send them in within the same packet it is ok but separate each claim using paper clips and do not staple.

If you do a telephone hearing and someone is speaking on the phone make sure you have a dedicated speaker phone –sometimes the judge can’t hear on yours so check them when you call in – make sure you keep to the point that you are reviewing.

If you have any questions or need assistance please contact;

Peggy at 800-401-3643/ email  peggy.walker@vgm.com

Ronda at 888-665-6518 / ronda.buhrmester@vgm.com