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Medicare Appeals Backlog

The Department of Health & Human Services (HHS) plans to clear all backlogs under their new rules. HHS estimates that the Notice of Proposed Rulemaking (NPRM) on proposed changes would reduce the number of appeals going to Administrative Law Judges. Some of the main HHS proposals include; removing some steps in the appeals process, revising minimum amount required to file an appeal, allowing senior attorneys to handle some matters, increasing adjudication capacity, and taking actions for reducing pending appeals.

Chief law judge of the Office of Medicare Hearings and Appeals (OMHA), Nancy Griswold, said that the backlog in above 700,000 Medicare appeals would be solved in 11 years, that is by 2021, provided that there is no change in the system and if no new appeals were included. Health care providers and beneficiary advocates had criticized OMHA on its inability to reduce backlogs and speed up appeals. As of now, a claimant has to wait for more than 2 years for a decision from hospitals, nursing homes, medical device suppliers, and other healthcare providers.

Independent audit contractors, who reject payments to hospitals, are the main cause of increasing such appeals. According to a study conducted by GAO, audit-related appeals increased 37-fold from 2010 through 2014 when compared to all other appeals, which increased only 1.5 times in the same period.

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Tom Nickels, Vice President of American Hospital Association Executive said that the group was “skeptical that these proposals will do more than scratch the surface of the severe backlog in ALJ appeals that has led to hospitals facing multi-year waits for hearings.”

He added that “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.”

New proposals and more funding are expected to decrease backlogs by streamlining the decision-making process, thereby decreasing cases that go to the third level of appeals where some cases wait for a hearing and decision. The proposed changes will be posted on the Federal Register website, and will be open for comments until 29 August 2016.

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