Medicare claims denials by recovery auditors (RACs) combined with more than 460,000 pending provider requests for administrative law judge (ALJ) review of those denials provoked sharp bipartisan criticism of CMS at a recent House Oversight Subcommittee hearing for failing to prevent the appeals jam.
 
Panel Chairman James Lankford, R-Okla., focused on how the two developments are driving durable medical equipment suppliers, physical therapy clinics and other providers to the wall by holding up their reimbursement for well over two years. As reported by the newsletter CQ HealthBeat, Lankford blamed the RAC audit process for the fact that too many of their Medicare claims are being unfairly denied that it takes too long to get a hearing to reverse decisions.
 
“Not many businesses can survive having their money held up for 28 months,” he commented in questioning Shantanu Agrawal, head of CMS’ Center for Program Integrity, which oversees the RACs. The subcommittee’s ranking Democrat, California Rep. Jacki Speier, also criticized the RACs’ claim denials, but he criticized panel Republicans as well for not backing an increase in the number of ALJs. Appeals to ALJs are 10 times the 2007 level “and we have not added one single person to respond” to those claims, he noted.