Court rules that SNF can't skip part of Medicare appeals process

Long-term care providers may not leapfrog standard administrative appeals in Medicare reviews, as one creative Louisiana nursing home was reminded last week.

Carrington Place of Springhill had asserted that a growing backlog in the Medicare administrative appeals process made it futile, and thereby created grounds for a waiver. A U.S. District Court judge, however, declined to lift a suspension of Medicare payments because, he said, the backlog is “not so egregious.” The suspension was imposed over alleged overpayments for therapy services, according to a Zone Program Integrity Contractor cited in published reports.

The Medicare appeals process currently has a backlog of more than 800,000 cases.

Carrington Place officials, said because they have been subject to an actual overpayment notice yet, they couldn't pursue the administrative review process and enter the backlog of appeals officially.

The Government Accountability Office last month reported to Congress the Medicare program will likely post $60 billion in losses from unrecovered overpayments or improper Medicare payments as a result of a huge backlog fueled by an 18-month audit moratorium that ends March 31.

Medicare trustees have most recently projected the Medicare program could become insolvent by 2030. The Council for Medicare Integrity, which represents Medicare recovery audit contractors, blamed the moratorium and other challenges for severely weakening a program that is already on a “fast track to insolvency.”