There is a huge backlog of pending appeals for Medicare reimbursements.
By the end of 2015, according to the government, there were a total of 898, 891 pending appeals, which would take about 11 years for the Office of Medicare Hearings and Appeals (OMHA) and 6 years for the Medicare Appeals Council (MAC) to process.
To address this backlog, the Department of Health & Human Services (HHS) released a notice of proposed rulemaking (NPRM) on June 28, 2016 to modify the appeals process.
More than 1.2 billion Medicare fee-for-service claims were processed in 2015, and about 10% were denied. Out of the total denied claims, approximately 3%, totaling 3.7 million claims, were appealed, according the HHS.
More Medicare claims have recently been denied because of the increase in beneficiaries due to the baby boomers and more disabled individuals and a national focus on integrity programs, such as the Recovery Audit Program.
More denied claims resulted in more appeals. The increase in appealed claims has led to a 442% increase in the number of appeals that go through the OMHA and a 267% increase at the MAC.
Proposed Changes
Here are the proposed changes:
- Expanding the number of available OMHA adjudicators,
- Increasing decision-making consistency across all appeals levels,
- Streamlining the process so adjudicators spend less time on repetitive issues and procedural matters.
Specifically, the proposed rule would grant the OMHA with the authority to identify certain decisions as precedential. This provision would hopefully increase consistency of decisions across all levels and provide clear direction to adjudicators on repetitive issues.
The proposed rule also would allow attorney adjudicators to review administrative records and draft appropriate orders for certain appeals rather than using an administrative law judge, who can be used to conduct other hearings.
Attorneys would only be able to develop orders for certain appeal requests, such as issuing dismissals based on an appellant’s request to withdraw from a hearing, remanding appeals for information, and holding reviews of other dismissals.
The provisions in the proposed rule are part of a three-part strategy to improve the Medicare reimbursement appeals process. The other components of the strategy include investing in new resources across the five levels of appeal, more funding, and adding new authorities to manage the appeals volume.
HHS has called on the healthcare community to submit comments on the proposed rule by August 29, 2016.
Hospitals Skeptical
Despite its potential to decrease the Medicare reimbursement appeals backlog, revcycleintelligence.com reports the American Hospital Association (AHA) has expressed uncertainty about the proposed rule.
“We are skeptical that these proposals will do more than scratch the surface of the severe backlog in ALJ [Administrative Law Judge] appeals that has led to hospitals facing multi-year waits for hearings, ” said Tom Nickels, AHA’s Executive Vice President. “We are deeply disappointed that HHS has not made more progress in addressing the delays despite the more than two years since the delays began.”
“Further, we find the timing of today’s proposals interesting, given that it’s just days before HHS was required to respond in court to show progress in resolving the backlog as part of our lawsuit challenging the ALJ delays.”
The proposed changes come almost a month after the Government Accountability Office (GAO) released a report that stated the appeals backlog was likely to persist despite HHS initiatives to provide more prompt adjudication.
Appeals Process Primer
The agency provided a link to: HHS Primer: The Medicare Appeals Process.
