On January 17, 2017, HHS published its final rule addressing modifications to the Medicare benefit claim appeals process. The final rule seeks to reduce the significant backlog of pending Medicare appeals and streamline the actual appeals process.
With the capacity to complete 92,000 appeals per year, HHS reports that there are currently more than 650,000 pending appeals. In light of this approximately seven-year backlog, the final rule seeks to revise the procedures HHS follows for appeals of payment and coverage determinations for Medicare enrollees. HHS notes that the number of appeals increased 1,222 percent from 2009 to 2014 and was accompanied with only a “modest” increase in HHS funding.
HHS has put forth a three-prong approach to address this increase in appeals and current backlog of claims waiting to be adjudicated. Specifically, this three-prong approach provides that HHS will:
1) invest new resources at all levels of appeal to increase adjudication capacity and implement new strategies to alleviate the current backlog;
2) take administrative actions to reduce the number of pending appeals and encourage resolution of cases earlier in the process; and
3) propose legislative reforms that provide additional funding and new authorities to address the appeals volume.
In this final rule, HHS states that it is pursuing its three-prong approach by implementing rules that expand the pool of available Office of Medicare Hearings and Appeals (OMHA) adjudicators and “by improving the efficiency of the appeals process by streamlining the processes so less time is spent by adjudicators and parties on repetitive issues and procedural matters.” For example, the final rule will allow attorney adjudicators the authority to decide appeals when decisions can be issued without an Administrative Law Judge hearing, to review certain dismissals, and to dismiss requests for hearings when the appellant withdraws, which HHS believes will allow Administrative Law Judges to conduct hearings and focus on more complex cases.
To further create process efficiencies, the final rule also permits designation of Medicare Appeals Council decisions (final decisions of the Secretary) as precedential. HHS believes this change will provide more consistency in decisions at all levels of appeal and reduce the appeal rates by providing clarity. Additionally, the final rule looks to simplify proceedings by limiting the number of entities, such as CMS or CMS contractors, that can be a participant or party at the hearing. Overall, HHS states that the final rule “will streamline the administrative appeal process, increase consistency in decision making across appeal levels, and improve efficiency for both appellants and adjudicators, and in particular benefit Medicare beneficiaries by clarifying processes and adding provisions for increased assistance when they are unrepresented.”
These regulatory changes in the final rule “are the latest in a series of administrative actions designed to reduce the number of pending appeals and encourage resolution of cases earlier in the Medicare appeals process.” Although HHS acknowledges that the final rule alone will not reduce the Medicare appeals backlog, HHS hopes that the combination of the FY 2017 proposed funding increase and the final rule will allow it to eliminate the Medicare appeals backlog by fiscal year 2020. The final rule will become effective March 20, 2017.
To view the Final Rule in its entirety, click here.
