On January 17, 2017, the Centers for Medicare & Medicaid Services (CMS) published a final rule
that seeks to improve the efficiency of the
Medicare appeals process. The final rule,
titled “Medicare Program: Changes
to the Medicare Claims and
Entitlement, Medicare Advantage
and Medicare Prescription Drug
Coverage Determination Appeals
Procedures,” follows a variety
of initiatives imposed by the
Department of Health and Human
Services (HHS) in an attempt to
reduce the increasing number of
appeals and the increasing backlog
of claims at the administrative law
judge (ALJ) level of hearing.1 The
reforms announced in the final
rule may streamline efforts and
increase efficiencies, but its overall
impact on the appeals backlog will take time
Various efforts by the Office of Medicare
Hearings and Appeals (OMHA) and CMS to
reduce the Medicare appeals backlog at the
ALJ level of appeal include alternative settlement options for eligible claims pending ALJ
hearing. These settlements, referenced as
the Settlement Conference Facilitation (SCF)
program, apply OMHA’s resources very efficiently and have the potential to resolve a
large volume of claims. The ALJ settlements
are also potentially excellent opportunities
for providers, because the backlog of ALJ
appeals has caused an extreme delay for ALJ
hearings despite the statutory requirement
that ALJs hold hearings and issue decisions
within 90 days of receipt of the ALJ hearing
request. However, HHS has projected that
the SCF process will reduce the number of
appeals pending before OMHA by 27,000 by
the end of fiscal year (FY) 2020. Under current resources (and without any additional
by Andrew B. Wachler, Esq. and Jessica C. Forster, Esq.
Medicare appeals process:
CMS publishes final rule
» Federal court ruling requires HHS to take action to reduce the Medicare appeals backlog.
» Additional efforts to reduce the Medicare appeals backlog are helping, but not completely relieving the Medicare appeals backlog.
» The final rule implements changes that will improve efficiencies throughout the Medicare appeals process, but are insufficient in
themselves to respond to the backlog.
» The final rule provides important regulatory clarification to longstanding components to the Medicare appeals process.
» The final rule will impact providers’ and suppliers’ strategic approaches to audits and appeals.
Andrew B. Wachler ( email@example.com) is Managing Partner and
Jessica C. Forster ( firstname.lastname@example.org) is Associate Attorney with Wachler
& Associates, PC in Royal Oak, MI.