ALJ Backlogs Improve
WASHINGTON, D.C. – AAHomecare recently met with the Office of Medicare Hearings and Appeals (OMHA) regarding the status of the Administrative Law Judge (ALJ) backlog. OMHA was court mandated to eliminate the ALJ backlog by the end of the Fiscal Year 2022.
OMHA noted that they received a voluntary extension on the deadline and were able to remove 99% of the backlog in March 2023. As of May 2023, OMHA received 26,985 appeals so far in FY2023 and of that, 11,850 are Part B appeals. OMHA unofficially shared with AAHomecare that roughly 72% of Part B appeals are for DMEPOS.
OMHA also shared the good news that they have been able to process ALJ appeals within 90 days for the last couple of months. This is good news for all Medicare healthcare providers and suppliers that previously had to wait years for a hearing. At its highest, average wait time was 1,430 days in FY 2020.
Medicare Advantage Updates
AAH Engages with Part C Leaders
AAHomecare is actively supporting efforts to improve oversight and transparency of Medicare Advantage plans to ensure Medicare beneficiaries have the same access to care as in Part B. As part of that effort, AAHomecare met last week with several senior CMS Part C leaders to develop relationships on that side of the Agency. Issues discussed included network adequacy concerns, inconsistencies between MA plans and FFS on prior authorization, and the need for data transparency from the plans.
AAHomecare Payer Relations subcommittees will work on providing follow-up information to CMS on specific issues raised in the meeting. A separate meeting between AAHomecare, the ALS Association, and CMS Part C leaders to address prior authorization issues for vents that are causing significant problems for individuals with neuromuscular disorders such as ALS is currently being scheduled.
Humana Partners with AdaptHealth and Rotech to Manage MA Plans
Effective July 1, 2023, Humana will enter into an enhanced partnership with AdaptHealth and Rotech to manage the Humana Medicare Advantage Health Maintenance Organizations (HMO) business in the following states:
AdaptHealth: AL, AR, CA, CO, CT, DC, DE, GA, IA, IL, KS, MA, MD, ME, MN, MO, NC, ND, NE, NH, NJ, NM, NV, NY, OK, PA, RI, SC, SD, TN, TX, VA, VT, WI
Rotech: Central North FL, IN, KY, LA, MI, MS, OH, WV
Each of these designated providers will have 90 days (or until Oct. 1, 2023, contingent upon medical necessity) to manage the transition of existing DME rentals that are with providers that will not remain in network after July 1, 2023. Humana is currently notifying members and referring providers about the change in network.
The following DME groupings should be submitted to the designated DME provider under this network change: respiratory supplies – mobility aids – wheelchairs and standard mobility – beds and support surfaces – supplies: ostomy, colostomy, urologicals, certain diabetic supplies.
These items may not be provided by the designated DME providers; other in-network providers can be found in Humana’s provider directory: prosthetics, custom orthotics, and diabetic shoes – mastectomy and wigs – hearing aids – custom power wheelchairs.
In a press release announcing the change, Humana stresses that this move “only pertains to Humana Medicare Advantage HMO plans. It does not pertain to Humana Medicare Advantage members enrolled in PPO or private fee-for-service (PFFS) plans, or Humana’s Medicaid, Commercial or TRICARE lines of business.”
AAHomecare’s Payer Relations Council has developed a list of questions that are being submitted to Humana to ensure that during this transition there is continuity of care for the patients impacted. The questions are also aimed at soliciting information to help the provider community in understanding the process and the parameters Humana has given in reimbursement for providers during and after the transition.
