ALJ Overturns Disputed Claims Against VieMed

An ALJ has overturned all disputed claims from a 2021 HHS OIG report, and Medicare Administrative Contractors have returned 100 percent of the recouped funds to the provider.

• By David Kopf
• Jan 26, 2023

An Administrative Law Judge with the Office of Medicare Hearings and Appeals (OMHA) has overturned all of the claims disputed by a 2021 HHS OIG report regarding non-invasive ventilators supplied by respiratory and HME provider VieMed Healthcare.

The ALJ’s decision resulted in Medicare Administrative Contractors returning 100 percent of the recouped funds to VieMed.

“We are extremely pleased with the judge’s decision in this matter, which reaffirms the high integrity of our clinical protocols and sets the record straight,” VieMed CEO Casey Hoyt said. “In addition to restoring our long-standing reputation as a best-in-class provider and industry leader, the extensive appeals process was important to us in order to ensure that the right patients continue to have timely access to this life-saving care.”

In the May 2021 report, the OIG reviewed the claims of 100 VieMed patients in an audit of home non-invasive ventilation claims. The OIG concluded that 98 percent of the sampled claims did not comply with Medicare requirements and asserted that the therapy was not necessary for those patients, which was in direct contradiction to the conclusions of the prescribing providers, according to VieMed.

In the report, the OIG recommended that CMS issue an extrapolated overpayment and recoup funds from VieMed.

Using the appeals process, VieMed disputed the OIG’s findings, arguing that the report ignored each patient’s diagnosis and supporting documentation from treating and prescribing physicians, and applied clinical guidelines that were contrary to CMS’s accepted standard of care.

The ALJ’s decision found all appealed claims in VieMed’s favor, resulting in a $0 overpayment for patient claims addressed by the OIG.

“The available data and research confirm that timely access to non-invasive ventilation in the home improves health outcomes while simultaneously driving down overall healthcare costs,” Hoyt added. “We will urgently communicate these compelling and clarifying results with payors and treating physicians so that more patients nationwide can receive the life-saving care they need and deserve.”

ALJ Appeals Decreasing

In related news, the American Association for Homecare reported that the Office of Medicare Hearings and Appeals (OMHA) published that the average processing time for an ALJ appeal for Fiscal Year 2022 decreased by 42 percent from FY 2021.

OMHA is required to process ALJ appeals within 90 days, AAHomecare noted, but OMHA has not met that requirement in more than 10 years. As part of the American Hospital Association lawsuit, OMHA was mandated by the court to have eliminated the backlog by the end of FY 2022.

The association added it is requesting additional data specific to DMEPOS ALJ appeals and noted that the VieMed case shows that DMEPOS audits need an improved review process.

“OIG reports can be highly influential and referenced regularly in policy changes and audit projects,” a statement from the association read. “This appeal win by VieMed highlights the concerns AAHomecare has communicated with government officials previously on how federal government auditors may not be qualified to audit DMEPOS claims. DMEPOS regulations are complex and require a seasoned auditor that is educated and knowledgeable of DMEPOS coverage criteria to be able to properly review DMEPOS claims.”