Backlog backlash: HHS says clearing Medicare backlog not possible

Just two months after a federal judge told the Department of Health and Human Services (HHS) to clear through a huge backlog of Medicare claims appeals comes word from the agency that not only will it not be able to comply, but that the backlog will actually grow by the time it’s supposed to have been eliminated.

According to published reports, HHS said in a recent status report to the court that it anticipates its 687,382-claim backlog to exceed more than a million by the end of fiscal year 2021, the timeline that the court had given it to eliminate the backlog.

As we wrote about in December, U.S. District Judge James E. Boasberg had ordered HHS to figure out how to reduce the backlog of pending cases before administrative law judges by 30 percent by the end of 2017, 60 percent by the end of 2018 and 90 percent by the end of 2019. All backlogged cases were to be eliminated by Dec. 31, 2020.

The status report – the first of many to be filed every 90 days per court order – suggests a lack of funding, combined with hospitals and providers who are unwilling to settle claims, are causing efforts to stall.

“Although the initiatives undertaken by HHS have significantly slowed the growth of the backlog, the significant annual reductions that this court has directed are not possible given current funding and legislative authorities,” HHS says.

Every year Medicare Administrative Contractors process about 1.2 billion fee-for-service claims on behalf of the Centers for Medicare & Medicaid Services (CMS) for more than 33.9 million beneficiaries. When beneficiaries or providers disagree with a coverage or payment decision, they have the right to appeal.

In January, the Centers for Medicare & Medicaid Services (CMS) published a final rule titled Medicare Program: Changes to the Medicare Claims and Entitlement, Medicare Advantage Organization Determination, and Medicare Prescription Drug Coverage Determination Appeals Procedures, which finalized proposed changes made to the Medicare appeals process. The rule, which is to take effect March 20, implements certain administrative and procedural actions designed to reduce the Medicare appeals backlog.

The Health Law Offices of Anthony Vitale can assist providers with Administrative Law Judge overpayment representation, as well as alternative overpayment settlement options with CMS. Contact us for additional information at 305-358-4500 or send us an email to info@vitalehealthlaw.com and let’s discuss how we might be able to assist you.