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Your Rights as a Provider

It is not my desire to create drama but then again, I am not the one who took away your rights as a provider.

Your contract with Medicare is simple.  It states that you are qualified to perform services for home health and hospice patients and Medicare will pay you according to an agreed schedule.  Occasionally, they review clinical records and refuse to pay based on their assessment of your chart.  If you agree with their decision as is sometimes appropriate, so be it.  If you feel as though you disagree with their decision, you can appeal.

Sort of…..

Last week, I heard a rumor started by the National Association of Home Care and Hospice that the ALJ’s weren’t going to be docketing any more cases from home health and hospice providers.  I knew this could not be the case so I emailed Mr. Dombi at NAHC and he responded by sending a scanned copy of a letter from the Chief Administrative Law Judge, Nancy Griswold confirming this complete and utter lunacy.

For those of you who do not work in the world of appeals and do more important things like take care of sick people in their homes, let me explain this to you.

Imagine you did something else for a living.  Humour me and pretend that you are a roofer.  My insurance company who supplies 95 percent of your business  agreed to pay you to put a roof on my house and you did a fine job.   You shingled my home with materials that will withstand a category 5 hurricane and then you sent a bill and my insurance company politely declined to pay it.   Since the services were covered under your contract, the advance Roof Recipient Notice won’t protect you and I am held harmless while enjoying the sound of the rain on my new Cat 5 roof.

You take your complaint to the board of insurance and they tell you that you are right!  You did install at Cat 5 roof on my house but it doesn’t matter.  No payment is forthcoming.  Their reasoning is that in order to begin work, they had you sign a 30 page contract and on page 27, halfway down, it said that in order to be paid, you must initial the bottom of every page of the contract.  You only initialed 15 pages.

You decide the whole world of roofers and contractors has gone crazy and decide to take the insurance company to court.  The problem is there is no judge to hear your case.

So, I get the roof.  You get nothing and you have no rights.  The insurance company who signed a contract agreeing to pay you is sitting pretty with another satisfied customer under a Cat 5 roof and all you can do is work harder and faster to make up for the lost dollars.

That is exactly what is happening with Medicare appeals right now.  Payment is being refused for up to half of all claims at some MACs (e.g. Palmetto GBA, NGS, CGS) and you do not have any right to appeal denials past a certain point.  There is no person that you can talk to and you are completely unsure if anyone is actually looking at your records before rubber stamping  ‘denied’ on your claim. In short, they don’t give a flying flip that you had to pay your nurses or cover supplies.

When I work appeals, most of my work is done with the ALJ in mind.  If it’s good enough for them, it should satisfy the lower levels of appeals but often it does not.  The ALJ is the first human being that you can plead with to be reasonable. Except in desperate and extreme cases, the appeals process ends there.

Ms. Griswold confidently speaks to the increase in the number of denials being appealed but she does not speak at all to the increase in denials that are fully appealable or the rate of denials being overturned by Administrative Law Judges for the first two levels of appeal.   If the first two levels of appeals were performed competently, the workload at the ALJ would naturally fall as a byproduct of efficient, ethical and fair clinical reviews.

She makes a very valid point that the number of cases has increased overwhelming the ALJ’s but instead of addressing the huge percentage of denials that should have never been, she asks for ‘indulgence’.  It’s like pouring salt into a wound.

How dare Ms. Griswold ask for indulgence when almost half of the claims for home health have been denied by some MACs for grammatical errors relating to the F2F encounter documentation?   She wants to thank us in advance even though she has the responsibility to be well aware that her staff is ultimately overwhelmed due to the enormous increase in unfair denials.

I beg for your indulgence when I say that someone in Washington, starting with Ms. Griswold needs to have the courage to stand up for the good providers and quit playing political games with the healthcare needs of our elderly.

According to the HHS website, Ms. Griswold can be reached at:

OMHA Headquarters
1700 N. Moore St., Suite 1800
Arlington, VA 22209

Phone: 703-235-0635;   Fax: 703-235-0700


Make use of this information.  If you don’t speak up now, you may not be able to later.

Thanks to NAHC for sharing this information freely without regard to membership status. The content and sentiment in this post are mine alone and should not be attributed to NAHC or any other entity or person. 

8 Comments Post a comment
  1. Pamela Willey #


    January 20, 2014

    • The consultant?

      January 21, 2014
      • Pamela Willey #

        No Julianne, me the owner/ Administrator. My question is if we are going to be denied no matter what, why spend hours going through that ADR chart with a fine tooth comb if they Pallmetto is going to take back our money anyway. Why is this Judge allowing them to do this. Heck, I am overwhelmed too, but I still take great care of my patients and still keep doing ALL the required documentation. Something MUST be done! If these people requesting ADR’s are not able to examine our charts, because they are overwhelmed, THEN QUIT SENDING REQUESTS! I don’t have the time nor the energy to prepare the charts to just get a stamp denied without them looking at them!

        January 24, 2014
  2. Rosia mays #

    I have heard it all. How can this be done when the law specifically mandates the specific levels of appeal? With no risk of ALJ overturning the denials, you can be sure that the # of denials will increase greatly

    The state and national home health organizations need to organize a collective effort to fight this

    January 20, 2014

    • I agree. When I shared the information with a lawyer friend of mine he assured me that I had been smoking crack and that it would require an act of congress, literally. Someone has been smoking crack but it was not me.

      January 21, 2014

  3. I did something a bit different. I went to whitehouse.gove and emailed the President requesting we get our right to appeal restored.

    Will anything come of it, probably not. Might as well go to the top thought

    January 20, 2014
  4. Debbie Mazzola #

    The RAC sends a list of numerous ADRs every 45 days knowing full well that they only get paid if they deny our claims. Sounds like a conflict of interest to me, but at least we could appeal all the way to the ALJ if necessary. Not anymore? How are we supposed to continue to provide care if we aren’t getting paid?

    January 24, 2014

    • I could be wrong but I think the RACs are paid a very handsome fee for review regardless of the outcome of their review. However, I imagine if they had a very low denial rate, contracts would be cancelled or not renewed.

      January 24, 2014

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