NAHC Submits Recommendations to Address Medicare Hearings Backlog
May 15, 2015 03:01 PM
NAHC submitted its recommendations to the Senate Finance Committee this week as a follow up to a recent Finance Committee hearing on “Creating a More Efficient and Level Playing Field: Audit and Appeals Issues in Medicare.” (See NAHC Report, April 29 for coverage of the hearing). At the hearing everyone agreed that the adverse effect on beneficiaries and providers makes it so important that Medicare appeals be heard in a timely and consistent fashion.
Under Medicare law a decision must be issued by a Medicare Administrative Law Judge (ALJ) within 90 days following the filing of an appeal by the Medicare beneficiary or provider. However, the appeal system is irreparably backlogged with nearly 900,000 appeals pending review before a handful of ALJs. With stepped up claims reviews in all provider sectors in Medicare, the number of appeals has increased exponentially. Despite efforts by the Office of Medicare Hearings and Appeals (OMHA) to expand the number of ALJs and achieve greater efficiencies in processing appeals, with 14,000 new appeals filed every week, a decision on any current ALJ appeal is years away.
In its statement for the record, NAHC asserted that alternative remedies must be considered as a means to reduce erroneous claim denials and resulting appeals. NAHC recommended the following:
CMS should take all necessary steps to improve the quality and accuracy of initial claim determinations to limit the need for an administrative appeal;
CMS should monitor its contractors that handle early-stage administrative appeals to ensure a high degree of accuracy and to reduce the number of appeals that end up before an ALJ;
CMS should provide a settlement option to all appellants with claims pending before an ALJ in order to reduce the backlog. That settlement should be based on historical data on ALJ reversal rates and the cost savings achieved by Medicare coming through the avoidance of an ALJ appeal; and
OMHA should increase its resources to handle the level of demand and establish alternative dispute resolution processes to resolve some appeals.
Senate Finance Committee staffers are hard at work on legislation to address the hearings backlog. NAHC met with Finance staff this week to discuss NAHC’s recommendations and thank the Committee for its leadership in addressing this urgent issue. NAHC and Finance staffers also discussed NAHC’s recommendations for reforming the home health face-to-face (F2F) physician encounter requirement, as the F2F requirement is a major reason for the backlog of Medicare home health appeals. Stay tuned to NAHC Report for coverage and analysis of legislative efforts to address the hearings backlog as well as reform the F2F requirement.