"The Ronan Report" provides insight about the activities at the Western Maryland Health System in Cumberland, Maryland, and about the changes taking place in healthcare today from a CEO's perspective.

Wednesday, January 8, 2014


Today, we received a letter from the Chief Administrative Law Judge (ALJ) with the Office of Medicare Appeals and Hearings.  The letter was to inform hospitals that an administrative law judge's decision on a Medicare claims denial appeal could now take up to three years to adjudicate.  Up until this point, the law required a decision within 90 days.

The reason for the delay: there is backlog of appeals from the Recovery Audit Contracting (RAC) Process.  So, instead of stopping or reducing the number of audits, they have increased the audits and, as a result, simply do not pay hospitals for the care that they have already rendered.  We currently have hundreds of cases in the RAC appeal process, tying up millions of dollars and now we find out that the delays will only get worse and never get better.  

The national backlog of appeals has grown to almost one half million and it continues to rise.  Previously, hospitals across the US simply budgeted for the RAC process and didn't appeal to the ALJ level.  Then, CMS stepped up the number of audits to the point where hospitals could no longer allow the audits to continue without appeal.  What is of great interest is that we have won every appeal at the ALJ level except one and even that one should have been ruled in our favor.  This is a broken process that everyone in Washington continues to ignore.

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