HHS Takes Another Shot at Reducing Medicare Appeals Backlog

In an effort to clear the ever-growing Medicare appeals backlog, the U.S. Department of Health & Human Services has announced the launch of two new settlement options for providers and suppliers: a low-volume appeals (LVA) settlement and an expanded Settlement Conference Facilitation (SCF) process.

LVA will be limited to appellants with a low volume of appeals pending at the Office of Medicare Hearings and Appeals (OMHA) and the Medicare Appeals Council. Specifically, those with fewer than 500 Medicare Part A or Part B claim appeals pending at OMHA and the Council, combined, as of Nov. 3, 2017, with a total billed amount of $9,000 or less per appeal could potentially be eligible, if certain other conditions are met. CMS will settle eligible appeals at 62 percent of the net allowed amount. However, further details are not yet available.

In addition, OMHA will be expanding the SCF process for certain appellants that are not eligible for the LVA option. SCF is an alternative dispute resolution process at OMHA and gives certain providers and suppliers an opportunity to resolve their eligible Part A and Part B appeals. During this process, a facilitator uses mediation to assist the appellant and CMS in working toward a mutually agreeable resolution.

OMHA has said additional information about this initiative will be available in the coming weeks. Providers and suppliers should monitor OMHA’s website for additional details.

The backlog of appeals has been an ongoing problem, with the average processing time for an Administrative Law Judge appeal at more than 1,082 days. As of June, there was a back log of 607,402 pending appeals. The backlog is expected to reach 950,520 by the end of fiscal year 2021.

As we wrote about nearly a year ago, a U.S. District Judge ordered HHS to figure out a way 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.

However, an appellate court overturned his order after HHS filed an appeal. The court found it was “abuse of discretion” to order HHS to abide by the schedule he set.

In August, CMS announced it was making changes to its Medicare audit strategy that would require Medicare Administrative Contractors (MACs) to focus on specific providers and suppliers. CMS says under this more targeted auditing approach “MACs will focus only on providers/suppliers who have the highest claim error rates or billing practices that vary significantly out from their peers.” By doing so, it also could cut back on the number of claims being disputed.

Whether this latest effort on the part of HHS to clear the backlog, or other initiatives underway, can make a dent in the huge backlog remains to be seen.

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.