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HHS Put Forth Proposal to Fix Medicare Appeals Process

Posted on July 6th, 2016


The Department of Health and Human Services, or HHS, put forth proposed key changes in the Medicare appeals process that is meant to help reduce the backlog of more than 700,000 cases. Nancy Griswold, chief law judge of the Office of Medicare Hearings and Appeal, recently said in an interview that if no changes were made to the system, it would take 11 years to eliminate the backlog.

The new proposals, as well as increased funding requests, are expected to eliminate the backlog by streamlining the decision-making process and reducing the number of cases that go to the third level of appeals, where many cases linger waiting for a hearing and then a decision from an administrative law judge. From the day of the hearing, it currently takes an average of slightly more than two years for a decision in appeals from hospitals, nursing homes, medical device suppliers and other health care providers.

Some of the proposed changes include:

  • Designate some decisions from the Medicare Appeals Council, the last of four stages of appeals, as precedents that decision-makers at lower levels would have to follow. This could eliminate redundant appeals and resolve inconsistencies in interpretation of Medicare policies.
  • Allow senior attorneys to handle some of the procedural matters that come before the administrative law judges, such as dismissing a request for a hearing after the appellant has withdrawn the request.
  • Revise how the minimum amount necessary to lodge an appeal is determined. Under current rules, an appeal must involve payment of at least $150, based on the amount the provider charged. HHs is proposing to use Medicare‚Äôs allowed amount instead, which tends to be lower, and that could reduce the number of claims that could be appealed.
  • Eliminate some steps in the appeals process to simplify the system.

The proposals do not address what hospital representatives say is a key cause of increasing appeals, independent audit contractors who can reject payments to hospitals.

The proposed changes will be posted on the Federal Register website and be open to comments through Aug. 29.

Visit here to read more about the proposal, as well as key opinions from both sides.

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