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Rahul Narula

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The Department of Health and Human Services (HHS) is ahead of schedule to reduce its Medicare Administrative Law Judge (ALJ) appeals backlog, as required by court order, but lawmakers are still looking for ways to improve the efficiency of the Medicare appeals process.

Following a November 1, 2018 federal district court order in American Hospital Association [AHA], et al., vs. Azar (C.V. No. 14-cv-00851) to reduce the Medicare appeals backlog, HHS reported a reduction of 31.4% through the end of the fourth quarter of 2019, according to the third status report[1] (the “Status Report”) filed by HHS to the United States District Court for the District of Columbia on December 31, 2019.  The Status Report identifies 292,517 appeals remain pending at the Office of Medicare Hearing and Appeals (OMHA).  The 2018 court order requires HHS to achieve a 49% reduction by the end of FY 2020 and to clear the backlog entirely by the end of 2022.

At the time of the court’s decision, OMHA had 426,594 appeals pending and providers were waiting up to five years for an ALJ decision, notwithstanding a 90-day deadline under 42 U.S.C. 1395ff(d)(1)(A).  With a 31% reduction so far, HHS is currently approximately 12% ahead of the court’s projected pace for reducing the backlog – at the time of the order, the court projected a 19% reduction by the end of fiscal year (FY) 2019.
Continue Reading HHS Continuing to Reduce Medicare ALJ Appeals Backlog under Court Order; Senators Reintroduce Legislation Striving to Improve Efficiency of Medicare Appeals Process

The Centers for Medicare & Medicaid Services (CMS) has issued a final rule streamlining the process for Medicare Parts A and B claims appeals and for Medicare Part D coverage determination appeals in order to “reduce associated burden on providers, beneficiaries, and appeals adjudicators.”  In particular, the final rule:

  • Removes the requirement in Medicare Parts

…

The Centers for Medicare & Medicaid Services (CMS) has proposed revising its rules governing the process Medicare beneficiaries, providers, and suppliers use to appeal adverse determinations regarding claims for Medicare Part A and Part B benefits or determinations for Part D prescription drug coverage.  According to CMS, the revisions “would help streamline the appeals process…

In the face of growing scrutiny and now judicial pressure, the Centers for Medicare & Medicaid Services (CMS) published a final rule on January 17, 2017 implementing certain administrative and procedural actions in an effort to reduce the significant Medicare appeals backlog. The final rule comes on the heels of intense criticism from various branches…

Medicare providers with pending cases at the administrative law judge (“ALJ”) level received positive news last week as a federal judge for the United States District Court for the District of Columbia (the “Court”) granted summary judgment in favor of the American Hospital Association (“AHA”) in its case against the Secretary of the Department of Health and Human Services (“HHS”).1

Since 2014, AHA has been litigating with HHS regarding HHS’ failure to meet statutorily-imposed deadlines for Medicare administrative appeals.2 On remand from the D.C. Circuit3 with instructions for further proceedings, the Court determined that there were equitable grounds to issue a writ of mandamus. The Court reasoned that even with certain good faith efforts made by HHS to reduce the backlog (such as a Proposed Rule4 issued this past summer), the appeals backlog was “still unacceptably high.”5 In its decision, the Court found that HHS did not “point to any categorically new administrative actions” and continues “to promise the elimination of the backlog only ‘with legislative action’ — a significant caveat.”6Continue Reading Court Orders HHS to Fix the Medicare Appeals Backlog by the End of 2020

The Department of Health and Human Services (HHS) has issued a proposed rule intended to address the significant backlog resulting from “an unprecedented and sustained increase” in Medicare appeals.  According to HHS, its Office of Medicare Hearings and Appeals (OMHA) had more than 750,000 pending appeals as of April 30, 2016, while it has only an adjudication capacity of 77,000 appeals per year.  This proposed rule comes following criticism from various branches of the federal government regarding the delay in processing Medicare appeals, including a recent Government Accountability Office Report (GAO-16-366) identifying opportunities to improve the appeals process; the D.C. Circuit Court of Appeals’ recent reversal and remand in American Hospital Association v. Burwell, 812 F.3d 183, 185 (D.C. Cir. 2016); and a Senate Finance Committee hearing in April 2015.

The proposed rule includes a series of reforms to speed the appeals process, including a provision to expand OMHA’s adjudicator pool by allowing OMHA to reassign a portion of its workload to non-Administrative Law Judge adjudicators.  Specifically, the proposed rule would allow attorney adjudicators to issue decisions when an appellant decides it does not want a hearing or withdraws his or her request for an ALJ hearing.  Decisions by attorney adjudicators can be reopened or appealed the same as if the ALJ made the decision.
Continue Reading HHS Proposes Rules to Streamline the Medicare Appeals Process to Address Backlog

Today President Obama signed into law H.R. 2, the “Medicare Access and CHIP Reauthorization Act of 2015” (MACRA), which reforms Medicare payment policy for physician services and adopts a series of policy changes affecting a wide range of providers and suppliers. Most notably, MACRA permanently repeals the statutory Sustainable Growth Rate (SGR) formula, achieving a goal that has eluded Congress for years. Now, after a period of stable payment updates, MACRA will link physician payment updates to quality, value measurements, and participation in alternative payment models.
Continue Reading President Obama Signs MACRA: Permanently Reforms Medicare Physician Reimbursement Framework, Includes Other Health Policy Provisions