CMS Releases Proposed Rule to Reduce Backlog of Medicare Appeals

In an effort to reduce the large backlog of Medicare coverage and payment appeals, the Centers for Medicare and Medicaid Services (CMS) released a proposed rule that would revise the procedures the Department of Health and Human Services (HHS) would follow at the Administrative Law Judge (ALJ) level for appeals of payment and coverage determinations. This proposed rule covers items and services provided to Medicare beneficiaries, enrollees in Medicare Advantage and other Medicare competitive health plans, and enrollees in Medicare prescription drug plans, as well as appeals of Medicare beneficiary enrollment and entitlement determinations, and certain Medicare premium appeals. In addition, the proposed rule would revise procedures that HHS would follow at CMS and the Medicare Appeals Council levels of appeal for certain matters affecting the ALJ level. As of April 2016, the Office of Medicare Hearings and Appeals (OMHA) had over 750,000 pending appeals, while OMHA’s adjudication capacity was 77,000 appeals per year, with an additional adjudication capacity of 15,000 appeals per year expected by the end of the current fiscal year. The proposed rule includes provisions to expand the pool of available OMHA adjudicators and improve the efficiency of the appeals process by streamlining the processes so less time is spent by adjudicators and parties on repetitive issues and procedural matters. The proposed rule was published in the July 5, 2016 Federal Register. Comments are due by Monday, August 29, 2016.