CMS Proposes Changes Designed to Speed up Medicare Appeals Process

It’s been a while since we last updated you on the latest about the Medicare appeals backlog, which although it has decreased some, remains troublesome.

To further address the issue, The Centers for Medicare & Medicaid recently proposed revising its rules that govern the appeals process in an effort to further streamline it and reduce the administrative burden on providers, suppliers, beneficiaries and appeal adjudicators.

The proposed changes are as follows:

Removal of the requirement that appellants in Medicare Parts A and B claims and Part D coverage determinations be allowed to submit appeal requests without a signature. CMS says by doing so it would help promote consistency between appeal request requirements and help adjudicators focus on the merits of the appeal rather than dismiss a potentially meritorious one for lack of a signature.

Change the time frame for vacating dismissal of appeal request for a Medicare Part A or B claim or Medicare Part D coverage determination. It would change from six months to 180 days. CMS reasons this allows sufficient time for adjudicators to carefully evaluate their dismissals, while taking into account the principle of administrative finality. Applying a time frame based on days, rather than months, leads to more consistency in interpretation and actual time frames, according to CMS.

Change the time frame for council referral. Provides that the date of receipt of the ALJ’s or attorney adjudicator’s decision or dismissal is presumed to be 5 calendar days after the date of the notice of the decision or dismissal, unless there is evidence to the contrary.

Make a number of changes to the CMS January 17, 2017 final rule streamlining Medicare appeals procedures to revise “several provisions that, upon further review, pose unanticipated challenges with implementation.” Here, CMS seeks to ensure the provisions are “implemented as intended, provide clarification and correct technical errors and emissions.”

Technical correction to actions that are not initial determinations. This is designed to make various corrections to address incorrect cross-references, inconsistent definitions and confusing terminology.

Comments on these changes are due no later than Dec. 5.

In August, HHS told a federal judge who ordered the agency to speed up the appeals process that the backlog has dropped more than 30 percent since last year. HHS says that as of July, the backlog stood at 445,000, down from about 652,000 a year earlier.

In December 2016, a federal judge gave HHS until 2020 to reduce the backlog.  The order grew out of a motion for summary judgement filed by the American Hospital Association.

In an effort to reduce the backlog CMS offered to pay hospitals 66 percent of the net allowable for short-term inpatient stays in exchange for dropping their pending appeals of denied claims.

In May 2017, a study published in the Journal of Hospital Medicine found existing and proposed reforms might not be enough to eliminate the 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 and let’s discuss how we might be able to assist you.

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