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Testimonials

In the various roles he has undertaken through the years, Val J. Halamandaris has been a singular driving force behind the policy and program initiatives resulting in the recognition of home health care as a viable alternative to institutionalization. His dedication to consumer advocacy, which enhances the quality of life and dignity of those receiving home health care, merits VNA HealthCare Group’s highest recognition and deepest respect. 

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VNA HealthCare Group

I have the highest respect for them, especially for the nurses, aides and therapists, who devote their lives to caring for people with disabilities, the infirm and dying Americans.  There are few more noble professions.

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President Barack Obama

Home health care agencies do such a wonderful job in this country helping people to be able to remain at home and allowing them to receive services

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U.S. Senator Debbie Stabenow (D-MI) Chair, Democratic Steering and Outreach Committee

Home care is a combination of compassion and efficiency.  It is less expensive than institutional care...but at the same time it is a more caring, human, intimate experience, and therefore it has a greater human element...it’s a big mistake not to try to maximize it and find ways to give people the home care option over either nursing homes, hospitals or other institutions

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Former Speaker of the U.S. House of Representatives Newt Gingrich (R-GA)

Medicaid covers long-term care, but only for low-income families.  And Medicare only pays for care that is connected to a hospital discharge....our health care system must cover these vital services...[and] we should promote home-based care, which most people prefer, instead of the institutional care that we emphasize now.

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Former U.S. Senator Majority Leader Tom Daschle (D-CD)

We need incentives to...keep people in home health care settings...It’s dramatically less expensive than long term care.

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U.S. Senator John McCain (R-AZ)

 

Home care is clearly the wave of the future. It’s clearly where patients want to be cared for. I come from an ethnic family and when a member of our family is severely ill, we would never consider taking them to get institutional care. That’s true of many families for both cultural and financial reasons. If patients have a choice of where they want to be cared for, where it’s done the right way, they choose home.

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Donna Shalala, former Secretary of Health and Human Services

A couple of years ago, I spent a little bit of time with the National Association for Home Care & Hospice and its president, Val J. Halamandaris, and I was just blown away. What impressed me so much was that they talked about what they do as opposed to just the strategies of how to deal with Washington or Sacramento or Albany or whatever the case may be. Val is a fanatic about care, and it comes through in every way known to mankind. It comes through in the speakers he invites to their events; it comes through in all the stuff he shares.

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Tom Peters, author of In Search of Excellence

Val’s home care organization brings thousands of caregivers together into a dynamic organization that provides them with valuable resources and tools to be even better in their important work. He helps them build self-esteem, which leads to self-motivation.

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Mike Vance, former Dean of Disney and author of Think Out of the Box

Val is one of the greatest advocates for seniors in America. He goes beyond the call of duty every time.

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Arthur S. Flemming, former Secretary of Health, Education, and Welfare

Val has brought the problems, the challenges, and the opportunities out in the open for everyone to look at. He is a visionary pointing the direction for us. 

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Margaret (Peg) Cushman, Professor of Nursing and former President of the Visiting Nurses Association

Although Val has chosen to stay in the background, he deserves much of the credit for what was accomplished both at the U.S. Senate Special Committee on Aging, where he was closely associated with me and at the House Select Committee on Aging, where he was Congressman Claude Pepper’s senior counsel and closest advisor. He put together more hearings on the subject of aging, wrote more reports, drafted more bills, and had more influence on the direction of events than anyone before him or since.

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Frank E. Moss, former U.S. Senator

Val’s most important contribution is pulling together all elements of home health care and being able to organize and energize the people involved in the industry.

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Frank E. Moss, former U.S. Senator

Anyone working on health care issues in Congress knows the name Val J. Halamandaris.

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Kathleen Gardner Cravedi, former Staff Director of the House Select Committee on Aging

Without your untiring support and active participation, the voices of people advocating meaningful and compassionate health care reform may not have been heard by national leaders.

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Michael Sullivan, Former Executive Director, Indiana Association for Home Care

All of us have been members of many organizations and NAHC is simply the best there is. NAHC aspires to excellence in every respect; its staff has been repeatedly honored as the best in Washington; the organization lives by the highest values and has demonstrated a passionate interest in the well-being of patients and providers.

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Elaine Stephens, Director of Home Care of Steward Home Care/Steward Health Systems and former NAHC C

Home care increasingly is one of the basic building blocks in the developing system of long-term care.  On both economic and recuperative bases, home health care will continue to grow as an essential service for individuals, for families and for the community as a whole.

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Former U.S. Senator Olympia Snowe (R-ME)

NCOA is excited to be part of this great event and honored to have such influential award winners in the field of aging.

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National Council of Aging

Health care at home…is something we need more of, not less of.  Let us make a commitment to preventive and long-term care.  Let us encourage home care as an alternative to nursing homes and give folks a little help to have their parents there.

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Former President Bill Clinton

Medicare Administrative Law Judge Hearings Update Report

February 14, 2014 10:02 AM

In early January, it was revealed that Medicare appeal hearings before an Administrative Law Judge (ALJ) would be facing significant delays due to a huge backlog of cases. On February 12, 2014, the Office of Medicare Hearings and Appeals (OMHA) held a public forum to detail the extent of the delays and its plans for expanding its ability to handle the increased caseload.

While OMHA appears to be doing everything within its power to schedule and hold hearings as soon as possible, it is very apparent that significant changes are necessary to address the growing crisis. Even with all the initiatives underway at OMHA, there is no way the backlog of nearly a half million appeals can be cleared.

In her December 31, 2013 letter, OMHA Chief Administrative Law Judge Nancy L. Griswold indicated that at that time there were 457,000 appeals awaiting assignment to an ALJ with 15,000 new cases added to the backlog every week. OMHA has only 65 administrative law judges to hear all of its cases.

NAHC earlier learned that approximately 26,000 of the backlogged cases involve home health services. The vast majority of the rest are hospital and DME appeals.

At the Forum, Chief ALJ Griswold explained that the backlog is due to an unanticipated increase in appeals volume. That increase is directly related to the expansion of post-pay claims reviews by the Medicare MACs, ZPICs, and particularly the RACs. She cited the sudden change in the number of appeals filed from 2012 to 2013 where ALJ hearing requests rose from 117,371 to 351,629. OMHA already was backlogged in 2012 because of the appeal growth in preceding years.

At this point, average ALJ appeal processing time has increased from 94.9 days in 2009 to 329.8 days in 2014. That extension of processing time will only get worse as the demand far outpaces the supply of ALJs.

OMHA has made great strides in increasing ALJ productivity through a number of efficiency measures. In 2009, ALJs handled an average of 2.2 cases per day and 551 per year. In 2013, productivity rose to 4.9 cases a day and 1,220 per year. However, even with that gain, it would take 375 ALJs to clear out the backlog in 12 months and 640 more to handle the new incoming cases each year. That translates to a conclusion that there is no readily available remedy to clear the backlog in the near term.

Griswold reported that OMHA has received an 18.6 percent increase in its budget for FY2015. That appears to be a proverbial “drop in the bucket” in comparison to what is needed.

Griswold and staff outlined several initiatives that are underway or under consideration. These include:

  • Issuance of an Adjudication Manual to improve decision consistency and production
  • The use of statistical sampling to resolve large groups of appeals
  • Employing Alternative Dispute Resolution and mediation to reach “Agreed Upon” decisions
  • Expanding the role of the ALJs’ Attorney Advisors including possible decision-making authority
  • Improving case management efficiencies through technological improvements such as web-based electronic case filing and processing

OMHA has limited authority as to what it can do under Medicare appeal rules. It is highly likely that amendments to Medicare laws and regulations will be necessary to achieve any significant improvement in resolving the appeal backlog and delays in addressing new appeals. The bottom-line is that productivity improvements alone cannot meet the appeal volume. With nearly 5 hearing decisions a day already issued by the ALJs, any productivity gains will be marginal. The quality of the hearing will suffer if ALJs are expected to produce more decisions.

NAHC has expressed that real solutions to the ALJ hearing crisis lie at the source of the problem. ALJ hearings are sought because appellants believe that earlier decisions by Medicare contractors are flawed. At the Forum, OMHA presented data on claim denials and appeals at earlier stages of the process. In FY2012, there were 15.9 million claim denials on 207 million claims under Part A Medicare with 120 million denials on 1 billion claims under Part B. RACs issued 634,000 of the Part A denials and 850,000 of those under Part B. At the first level of appeal, there were 583,000 processed under Part A and 2.9 million under Part B. Home health appeals represented 19% of the Part A appeals with only a 3.9% reversal rate. There were 234,000 Reconsideration appeals under Part A with 26% coming from home health at a paltry 1.4% reversal rate.

Clearly, the ALJ workload is directly related to the increased volume of claims denied by MACs, ZPIC, and RACs along with the low reversal rates at Redetermination and Reconsideration appeal steps. An improvement in the quality of initial decisions and the early-stage administrative appeals could greatly mitigate the need for ALJ hearings.

NAHC has recommended the following reforms to address the current appeal crisis and future appeal needs:

  1. Improve initial claim determinations by Medicare contractors. NAHC recently presented CMS with hard evidence that a ZPIC is using wholly illegal coverage criteria to review home health services claims. CMS is working to correct the ZPIC’s wholesale misunderstanding on Medicare coverage standards. Reducing erroneous initial determinations addresses the root cause of the high increase in appeals volume.
  2. Improve the quality and accuracy of Redeterminations and Reconsiderations. The very low reversal rates on home health claims at the early appeals stages triggers more appeals to ALJs. Home health agencies report a high success rate before ALJs. If more appropriate decisions are issued at the earlier appeals, the need for ALJ hearings decreases.
  3. Reduce post pay claims reviews. HHAs report a surge in claims reviews combined with unsupportable decisions. The volume of face-to-face encounter related denials has grown exponentially. If CMS revised and clarified its documentation demands, claims reviews and denials would drop significantly.
  4. Offer a settlement option on ALJ appeals that is correlated with average reversal rates. This approach would reduce appeals greatly although a settlement would not provide a 100% win for providers.
  5. Withhold recovery of alleged overpayments and waive interest charges pending the ALJ decision. With expected wait times of 30+ months, providers should not have to pay back a disputed claim until the appeal is completed.
  6. Require state Medicaid programs that pursue Medicare payment on dual-eligibles to use a sampling process for appeal adjudication. CMS offered a demonstration project for several years where states could reconcile disputes with Medicare through a sample of appeals. CMS abandoned that effort despite its efficiency.

All provider sectors are concerned about the ALJ hearing backlog. NAHC has met with Congressional committees that are looking for solutions to this crisis. It is apparent that the hiring of legions of new ALJs is not happening in the near term. Even if there were funding for hundreds of more ALJs, the training and implementation time is such that the backlog would grow by multiples of 3 to 5 before it is under control. NAHC will continue to press for systemic changes throughout the Medicare decisions process to bring about effective improvements.

 

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