Medicare Appeal Proposal Falls Far Short of Court Mandate

For years the hospital industry has been in an uproar over the mountainous backlog of Medicare claim appeals.  Current estimates are that a whopping 650,000 claims are at the Administrative Law Judge level awaiting adjudication.  Worse yet, the backlog has been growing at a dizzying rate, with requests for ALJ hearings increasing 1,222% from 2009 to 2014.

The situation has grown so bad that last month a federal court, albeit reluctantly, ordered HHS to meet a timeline calling for a 30% backlog reduction by the end of this year and a total elimination by the end of 2020.  AHA v. Burwell, Civ. Action No. 14-851 (D.D.C.)

On Jan. 17 HHS published a new rule reflecting first steps in addressing the problem.  By any standard they are baby steps, and tiny ones at that.  HHS estimates that the rule will reduce the number of appeals reaching ALJs by 24,500 annually.  That’s well short of the court-ordered 30% reduction by this year-end, which would be about 195,000.

The rule will (1) empower the Departmental Appeals Board chair to designate certain decisions of the Medicare Appeals Council as “precedential” across all CMS departments and (2) empower “Attorney Adjudicators” to resolve matters that in their judgment don’t require an ALJ hearing.

The rule, RIN:0991-AC02, goes into effect March 20, 2017.

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