CMS Addresses Backlog in Medicare Appeals

The Department of Health & Human Services (HHS), Centers for Medicare & Medicaid Services (CMS) issued a final rule effective March 20, 2017, changing the Medicare appeals procedures followed by HHS. The CMS rule attempts to decrease the backlog that has forced providers to wait over 900 days, on average, for an administrative law judge hearing. The new rules allow precedential decision-making at the Department Appeals Board level to increase consistency in decisions, and attorneys to hear appeals instead of administrative law judges.

HHS will publish all designated precedents on a website and these precedents will bind all lower-level decision-makers. HHS believes the number of appeals will decrease as providers are able to decide what claim denials or decisions should be appealed, based on review of the prior decisions.

As part of the effort to reduce the backlog in claims, HHS is also:

• Asking for additional resources for all appeal levels to boost adjudication capacity.
• Implementing administrative changes to decrease the number of pending appeals.
• Introducing legislative reforms, such as more funding for new authorities to manage the volume of appeals.

Currently, however, the future of the regulation is uncertain due to the President’s recently issued “Freeze Memo” which raises doubts about the implementation dates of all pending regulations. See our Health Law Alert published with this Health Law Update for further information.