Home Health & Hospice Week

A new lawsuit from a North Carolina home health agency takes aim at the Medicare appeals backlog.

“As a result of increasing audit activity by HHS contractors, providers have experienced extraordinary delays in the appeals process, particularly at the [Administrative Law Judge] level, which has effectively barred providers from challenging payment denials in a timely and efficient manner,” protests a complaint filed by Five Points Healthcare of NC LLC d/b/a Native Angels Home Health Agency Inc. filed on May 23.

“Not only has the extraordinary delay stymied timely appeals, it also violates the statute, which requires the ALJ to hold a hearing within 90 days of an appeal being filed,” continues the complaint from the Pembroke-based HHA. “Instead, providers such as Native Angels often wait up to 5 years to have their claims heard by an ALJ. In many instances, the ALJ will deny the provider a hearing based on a technicality or uphold the prior ruling without a hearing, which further deprives the provider of its due process rights.”

The suit outlines an appeal of a 2014 claim reviewed by Zone Program Integrity Contractor AdvanceMed. Problems in the appeal case included the HHH Medicare Adminis­trative Contractor denying an appeal due to the ZPIC submitting documentation late. “On May 14, 2020, the ALJ, after a more than 4-year delay, issued a dismissal order of Plaintiff ’s request for reconsideration without conducting a substantive hearing on the merits of the action,” the complaint says.

The agency asks for “damages in the amount of at least $3,691.30” — about twice the original claim amount — as well as “costs … and attorneys’ fees.”