Tuesday, January 28, 2014

Medicare Appeals Process Clogged

Dianne De La Mare, VP, Legal Services
Dan Ciolek, Senior Director, Therapy Advocacy


According to the Office of Medicare Hearings and Appeals (OMHA) Chief Administrative Law Judge, the agency’s 65 ALJs have been swamped by a tremendous increase in Medicare appeals for Parts A and B claim determinations. The weekly influx of hearing requests surged from an average of 1,250 in January 2012 to more than 15,000 in December 2013, creating a backlog of more than 460,000 appeals. Consequently, OMHA stopped assigning new hearing requests from providers in July 2013 (beneficiaries' appeals continue).

AHCA/NCAL staff has been addressing SNF-related issues that have directly contributed to the ALJ backlog. In particular, AHCA/NCAL has repeatedly pinpointed and predicted that Manual Medical Review (MMR) process for Part B therapy that was rolled out beginning in October 2012 was problematic. AHCA/NCAL has strongly urged CMS to better plan and manage the first couple levels of medical review properly (e.g. better targeting and better provider and contractor guidance), to avoid so many ALJ appeals. The Association has also been addressing individual membership MMR issues on a case-by-case basis with CMS staff.

In two letters to CMS administrator Marilyn Tavenner, the Association has addressed Part B therapy issues that refer to MMR problems that are contributing to the appeals backlog. The first is the 9/6/13 AHCA comments to the proposed 2014 Medicare Physicians Fee Schedule Rule. The second is the 9/10/13 Therapy Cap Coalition letter voicing significant concerns to Taverner on this issue as it relates to Medicare RAs’ practices that are driving up the appeals backlog.

In addition, AHCA has been lobbying Congress (including offering case examples of member MMR problems) to assure that claims are processed and reviewed accurately the first time so that unnecessary and costly appeals are avoided. In fact, AHCA/NCAL asked Congress to retool the Medicare Parts A and B appeals process system by adopting a framework that included three steps:
  1. Protect beneficiary access from care disruptions by strengthening the ten day MMR requirement.
  2. Improve the MMR process by simplification, standardization, and automation of contractor and provider communications.
  3. Require a GAO analysis of the MMR process to identify opportunities to better design and tailor the part B therapy benefit, and to improve the MMR process to better target medical review of outliers. 
AHCA will continue to push for reform of the appeals process to avoid these major disruptions in the future.

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