OMHA to expand Medicare appeals process


A blue door with two small holes in it.Faced with skyrocketing processing times, the Office of Medicare Hearings and Appeals (OMHA) says it plans to expand its Settlement Conference Facilitation pilot project in an effort to clear through the ever-growing backlog of claims appeals.

The pilot project, which began in June 2014, is an alternative dispute resolution process. It was created to bring the appellant and the Centers for Medicare & Medicaid Services (CMS) together to discuss the possibility of a mutually agreeable resolution for claims appealed to the Administrative Law Judge (ALJ) hearing level of the Medicare claim appeals process.

According to published reports, the number of appeals to Medicare has climbed from 60,000 claims in 2011 to 654,000 in 2013. The wait also has jumped from 220 days in 2013 to an average of 572 days in 2015.

The U.S. Department of Health and Human Services (HHS) reported that under Phase I of the pilot project more than 2,000 appeals had not yet been assigned to an ALJ for hearing.

On Oct. 15, at 1 p.m. OMHA will hold an open-door conference call with Part B providers to discuss how to request a settlement and outline the new process. OMHA has not provided any details on how it plans to expand the pilot project.

Those Part B providers who want to participate in the conference call must complete a registration form and email it to omha.scf@hhs.gov.

Currently, to take part in the pilot project, Part B providers must have at least 20 claims or $10,000 in controversy; must appeal all claims for the same service; and must have filed the claims in 2013. None of the claims can be currently assigned to a judge.

Last October, the American Hospital Association sued HHS asking for a court order for Medicare to abide by a 90-day timeframe for deciding appeals. The AHA blamed the backlog on overly aggressive recovery audit contractors who have “clamped down on perceived overpayments in recent years.†However, that lawsuit was later tossed out with the judge saying it was a matter for Congress and not for the courts to resolve.

The Health Law Offices of Anthony C. Vitale has extensive experience representing clients in audits and overpayments and we can represent your interests through all of the stages of the overpayment appeals process in an effort to achieve the most successful results.

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