Office of Medicare Hearings and Appeals Seeks Input on Ways to Reduce Medicare Appeal Backlog
November 11, 2014 03:41 PM
The Office of Medicare Hearings and Appeals (OMHA) has published a “Request for Information” regarding the Administrative Law Judge (ALJ) Program for Medicare Claim Appeals. The Request follows a recent OMHA Medicare Appellant Forum held in Washington, D.C. where OMHA officials detailed the ever-increasing appeal backlog along with its initiatives to bring greater efficiencies and productivities into the ALJ appeal process.
Nearly 900,000 ALJ level appeals are awaiting assignment and processing. The assignment of appeals to ALJs has been suspended since July 2013 due to the volume of pending appeals. The majority of the backlogged appeals involve hospital challenges to retroactive claim rejections by a Recovery Audit Contractor. The second highest volume involves Durable Medical equipment appeals, primarily because of the monthly rental billings method. It is estimated that there are approximately 30,000 home health and hospice ALJ appeals pending, many of which stem from state Medicaid program appeals involving dual-eligibles.
Since the explosion in backlogged appeals began, OMHA has instituted a wide range of improvements designed to take advantage of technological innovations, streamlined processing systems, and additional monies in its budget. For example, OMHA recently open a Kansas City regional office with seven ALJ teams capable of handling 7,000 hearings a year. However, it is highly unlikely that these improvements will do more than put a dent into the 13-14,000 new hearing requests received each week.
Still, OMHA wants to hear from anyone with a good idea. It is expected that the OMHA settlement conference option will soon become operational. Also, the use of a voluntary appeals sampling approach is underway for those providers with multiple appeals in the backlog.
NAHC views the backlog as insurmountable in the absence of intervention by the Centers for Medicare and Medicaid Services (CMS). Earlier this year, NAHC recommended that CMS institute a mass settlement option that offers the home health and hospice community a quick and simple process for a compromise settlement based on historical ALJ reversal rates.
CMS recently announced a similar settlement option to hospitals wherein an appellant hospital would receive 68 cents per dollar in dispute to drop its appeals. With the high volume of face-to-face physician encounter denials inflicted on home health agencies, a comparable settlement option might be worth considering. NAHJC is continuing in its efforts to create such an option as an alternative to waiting for an ALJ hearing several years from now.
NAHC also believes that the hearing backlog is due, at least partially, to avoidable errors in the initial decisions issued by Medicare contractors. For example, home health agencies are receiving face-to-face physician encounter denials that are based on the failure of the physician to include “MD” after his/her signature. While NAHC finds no support for such denials in Medicare rules and regulations, at a most it is a minor error or omission that the provider should be permit to correct rather than resort to costly appeals.
The Request for Information can be found here. Comments must be submitted no later than 5PM EST on December 5, 2014.