Senate Committee Shines Light on Medicare Appeals Claims Backlog
The Senate Finance Committee is calling for increased attention to an accumulating backlog of Medicare appeals claims, The Hill reports (Ferris, The Hill, 4/28).
According to Modern Healthcare, the Office of Medicare Hearings and Appeals' current appeals backlog has reached more than 500,000 cases for the first three of five appeals claim levels. The time it takes for an appeal to be processed has increased from an average of about 95 days in fiscal year 2009 to a projected 547 days in FY 2015 (Dickson, Modern Healthcare, 4/28).
Officials Cite Record Number of Filed Appeals, Low Funding
During a committee hearing on Tuesday, OMHA officials said they are receiving a record amount of appeals and blamed a lack of resources for the backlog. According to The Hill, the office received 700,000 appeals claims in FY 2013, up from 60,000 claims that were submitted in FY 2011. Meanwhile, the number of employees working on such claims has remained at 60, according to Sen. Ron Wyden (D-Ore.). Wyden added, "It's no wonder that the appeals system is buckling under its own weight" (The Hill, 4/28). Further, Wyden said the backlog has become so large that the office is no longer hearing new appeals cases (Modern Healthcare, 4/28).
OMHA Chief Law Judge Nancy Griswold said the office "feel[s] the urgency" of the claims and is "keenly aware of the impact that these delays are having." She urged support for President Obama's FY 2016 budget proposal, which she said would double the office's capacity to work on the appeals.
Griswold supported a proposal by Wyden to implement a refundable filing fee to help keep providers from filing claims just to "gam[e] the system." She said, "I think filing fee[s] would encourage appellants to take a closer look at what they are appealing" (The Hill, 4/28). For example, Griswold noted that about 51% of the claims filed this year have been submitted by five organizations, which she views as evidence supporting the need for a filing fee (Young, CQ HealthBeat News, 4/28).
In addition, CMS could change the initial level of appeals to help streamline or avert access to following appeals levels, according to Sandy Coston, CEO of Medicare administrative contractor Diversified Service Options. For example, Coston said that contractors could triage claims that involve clinical decisions to second-level appeals, which are overseen by qualified independent contractors and often involve provider input. She said, "Limiting the MAC appeal casework to those nonclinical cases would allow the MAC to focus its dollars on the cases most likely to be reversed at this level."
Thomas Naughton, senior vice president of the QIC Maximus Federal Services, suggested increased use of electronic records could help to reduce the backlog because QICs would no longer have to provide administrative law judges at OMHA with paper files. He said, "Fully electronic communication and access to a case will provide the program significant time and cost efficiencies while ensuring access to the complete case file" (Modern Healthcare, 4/28).
Committee Chair Orrin Hatch (R-Utah) refrained from endorsing a specific proposal to help reform the Medicare appeals claim system, but called for increased attention to the issue. He said, "We understand that handling a large volume of appeals is a daunting task," adding, "We must work in tandem i[f] the process is to be reformed" (The Hill, 4/28).This is part of the California Healthline Daily Edition, a summary of health policy coverage from major news organizations. Sign up for an email subscription.