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Medicare Appeals Procedures

Recently, CMS proposed a few changes to the “…procedures that the Department of Health and Human Services would follow at the Administrative Law Judge level for appeals of payment and coverage determinations for items and services furnished to Medicare beneficiaries, enrollees in Medicare Advantage and other Medicare competitive health plans, and enrollees in Medicare prescription drug plans.” According to the agency, these proposed changes would speed up the Medicare appeals process and eliminate backlog.

The Medicare appeals have increased greatly in the past couple of years. The Office of Medicare Hearings and Appeals (OMHA) even reported that there has been an increase of around 1,222 percent of trials for an Administrative Law Judge (ALJ) from the year 2009 to 2014. CMS highlights that this increase has drained OMHA’s resources significantly, and delayed the decision-making.

Regardless of significant increase in productivity, CMS states that the number of hearings and requests for reviews to ALJ continue to go beyond OMHA’s ability to deliver judgment. Although OMHA’s arbitration capacity is expected to increase by 15,000 by the end of this year, which is 77,000 appeals per year now, the agency already has over 750,000 pending appeals as of April 30, 2016.

CMS recommended allowing a few decisions from the Medicare Appeals Council to be made precedential. They conduct reviews of ALJ dismissals and decisions and issue a final decision of the Secretary of Medicare appeals. Traditionally, non-judicial decisions regarding payment policy or coverage are not given precedential value.

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CMS said that there have been many “fact specific” cases in the past, where it was impractical to assume and precedent from one case, which could be applied to another following case. However, by permitting some restricted precedential value, there is chance of increasing consistency in decision-making at different levels of appeal, besides helping in determining a logical move on recurring appeals.

According to the CMS proposal, introducing well-trained Attorney Adjudicators for certain settlements could reduce the workload of an ALJ. The agency said that this would allow Attorney Adjudicators to pass decisions for appeals that don’t necessarily need an ALJ hearing. CMS experts estimate that around 23,650 appeals could be processed by Attorney Adjudicators per year at a lower cost, if the proposed law comes to effect.

The proposal by CMS also aims to revise the basis of calculating the minimum amount for hearings by the Secretary and for judicial review that are established by Federal laws, but without changing the threshold amount that is fixed at $150.

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