CMS Finalizes New Rule to Reduce Medicare Appeals Backlog

February 2017 ~

In effort to reduce the significant Medicare appeals backlog, CMS finalized regulations for the Medicare Program: Changes to the Medicare Claims and Entitlement, Medicare Advantage Organization Determination, and Medicare Prescription Drug Coverage Determination Appeals Procedures. According to The U.S. Department of Health and Human Services (HHS), the final rule streamlines administrative appeal processes, increases consistency in decision making across appeal levels, and improves efficiency for both appellants and adjudicators.

According to HHS data from July 2016, the Office of Medicare Hearing and Appeals (OMHA) the number of requests received for an administrative law judge hearing or review jumped an alarming 1,222% between 2009 and 2014. And while the OMHA’s adjudication capacity was only 92,000 appeals per year, OMHA faced a Medicare appeals backlog of over 650,000 pending appeals by September 30, 2016, HHS reported. Providers on average had to wait about 935.4 days for an administrative law judge hearing, about ten times longer than the 90-day statutory limit.

In response to this, HHS released a final rule aimed at decreasing the Medicare appeals backlog on Jan. 17 following a court order for HHS to eliminate all pending appeals at the administrative law judge level by December 31, 2020.

As stated the final rule, “HHS is pursuing the three-prong approach by implementing rules that expand the pool of available OMHA adjudicators and improve the efficiency of the appeals process by streamlining the processes so less time is spent by adjudicators and parties on repetitive issues and procedural matters.”

HHS’s three-pronged approach to the issue includes:

  • Asking for additional resources for all appeal levels to boost adjudication capacity and eliminate the existing backlog;
  • Implementing administrative changes to decrease the number of pending appeals;
  • Introducing legislative reforms, such as more funding for new authorities to manage the growing volume of appeals.

Effective March 20th, HHS’ final rule establishes precedential decision-making policies at the Departmental Appeals Board level. The board’s chair will have the authority to identify a final appeal decision as issued by the Medicare Appeals Council as precedential.

HHS intends the board’s expanded authority to “increase consistency in decisions at all levels of appeal for appellants” and will allow the ALJs to “focus more on substantive issues in the hearings,” and give the Departmental Appeals Board, Medicare Appeals Council authority to handle the next level of appeals.


Source(s):  HHS Fact Sheet, January 17, 2017;  HHS, January 17, 2017; Federal Register, January 17, 2017;  RevCycleIntelligence, January 17, 2017; AAMC, January 19, 2017; Becker’s ASC Review, February 1, 2017;