Legal logjam in Medicare appeals process

The Office of Medicare Hearings and Appeals (OMHA) held a forum Wednesday to strategize on how to reduce the caseload logjam in the Medicare appeals process. The growing backlog of appeal cases is resulting in massive delays before providers can challenge coverage denials issued by the Centers for Medicare and Medicaid Services (CMS). Currrently, the wait time for an adjudication by an Administrative Law Judge—a Level 3 appeal—is more than two years.

Although Medicare Part B appeals have increased by about one-third each year since 2009, Medicare Part A appeals have surged from less than 25,000 cases in 2009 to an estimated 225,000 cases in 2013, according to an OMHA presentation. Administrative Law Judges made about 2 case decisions per day in 2009, but now handle nearly five decisions per day.

While appeals cases have increased significantly, the number of Administrative Law Judges has remained between 59 and 65 for the past five years, notes the OMHA presentation. Other issues complicating the request processing time are duplicate hearing requests, incomplete documents, a case filing system that is paper-based rather than electronic, and a lack of online information on appeal status.

Suggested strategies for trimming the problem include adopting an electronic case processing system, improving consistency among judges, and launching mediation pilots.

Many providers feel the caseload problem could be solved by more careful audits and streamlined claims processing. "There needs to be fewer inaccurate Medicare contractor audits—which are increasing appeals significantly—or additional resources provided to OMHA," said Mark Parkinson, president and CEO of the American Health Care Association. "If not, the backlog could cause disruptions to beneficiary access to healthcare, especially to nursing and therapy services."

Topics: Executive Leadership , Medicare/Medicaid , Regulatory Compliance