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LAFAYETTE, La. – Viemed Healthcare’s recent victory at the administrative law judge level of the Medicare appeals process is as much a win for the company as the HME industry, says CEO Casey Hoyt.
Earlier this month, an ALJ judge ruled in favor of Viemed, overturning all remaining disputed claims for non-invasive ventilation related to the findings of an Office of Inspector General report and ordering CMS to return 100% of the previously remitted funds to the company.
“DME (providers) are the ones in the home – we see the need for patients to have access to this level of care,” Hoyt said. “Without it, they’d pass away. We had the confidence to fight.”
Viemed enlisted the law firm K&L Gates and spent four years and $1.5 million to appeal findings from the OIG, which in 2021 issued a report stating that some of the company’s claims didn’t meet medical necessity.
From the start, Viemed was confident that its claims passed muster, says Hoyt.
“First, we had the physician’s diagnosis, and we had the physician’s notes – we followed the rules as CMS laid them out,” he said. “Second, 42 of the 100 claims had already been through a complex medical review in years prior. So, we knew that almost half the (claims) were already approved by CMS. That gave us the confidence to fight for the rest.”
Viemed also knew that fighting the OIG’s findings was the right thing to do by patients.
“This saves lives – it keeps people out of the hospital, out of the ER,” he said. “This is not something we should have a red flag going up on. We should have a green flag going up on how we are able to keep patients in the home.”
Viemed’s experience underscores the need for clear, consistent Medicare coverage criteria, something providers of NIV therapy have long said is lacking, says Hoyt.
“The guidelines create confusion for the auditing bodies,” he said. “We go off what we have in front of us and that’s what the auditors should be going off of. Auditors are asking us to go back and question a physician’s decision for therapy. That’s a position that DME has always been in.”