Judge Orders HHS to Clear Medicare Claims Appeal Backlog by 2020

Four years, that’s how long a federal judge has given the Department of Health and Human Services (HHS) to clear through a huge backlog of Medicare claims appeals. The Dec. 5 ruling, from Judge James E. Boasberg grew out of a motion for summary judgment filed in October by the American Hospital Association.

At issue are hundreds of thousands of Medicare claim appeals pending before HHS Administrative Law Judges. Judge Boasberg adopted the AHA’s suggested timetable to eliminate the backlog.

By the end of next year, HHS must have a 30 percent reduction of the current backlog of cases; by Dec. 31, 2018, it must have a 60 percent reduction; and by the end of 2019, a 90 percent reduction. All backlogged cases must be eliminated by Dec. 31, 2020. In addition, HHS must submit status reports to the court every 90 days outlining its progress.

According to HHS, ever 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. There are five levels to the appeals process:

• Redetermination
• Reconsideration
• Administrative Law Judge hearing
• Medicare Appeals Council review
• Judicial review in U.S. District Court

From FY 2010 through FY 2015, the Office of Medicare Hearings and Appeals (OMHA) realized a 442 percent increase of appeals annually. During the same time, the Medicare Appeals Council  (MAC) saw an overall 267 percent increase in the number of appeals it received annually. As a result, as of the end of FY 2015, 884,017 appeals were waiting to be adjudicated by OMHA and 14,874 were waiting to be reviewed at the MAC.

Last month, CMS announced it would offer to pay hospitals 66 percent of the net allowable for short term-inpatient stays in exchange for dropping their pending appeals of denied claims – all in an effort to reduce the backlog.

Prior to that, in July, HHS issued a proposed rule that it said would streamline the administrative process. You can read more about that here.

The deadlines that HHS faces are aggressive and the agency will have to take significant steps in order to meet them.

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.