Tag Archives: Appeals

CMS Announces CY 2018 Amount in Controversy Thresholds for Medicare Appeals

CMS has released the calendar year (CY) 2018 amount in controversy (AIC) threshold amounts for Administrative Law Judge (ALJ) hearings and judicial review under the Medicare appeals process. The CY 2018 AIC threshold amounts are $160 for ALJ hearings (the same as 2017) and $1,600 for judicial review (compared to $1,560 in 2017).  These amounts … Continue Reading

CMS Call to Focus on Changes to the Medicare Claims Appeal Process and Statistical Sampling (June 29)

CMS is holding a call on June 29, 2017 to discuss recent regulatory changes intended to streamline the Medicare administrative appeal processes, reduce the backlog of pending appeals, and increase consistency in decision-making across appeal levels. The call will also cover how certain appeals pending at the Office of Medicare Hearings and Appeals “may be … Continue Reading

CMS Finalizes Rule to Reduce Medicare Appeals Backlog

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 … Continue Reading

Court Orders HHS to Fix the Medicare Appeals Backlog by the End of 2020

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 … Continue Reading

CMS to Host Calls on Hospital Appeals Settlement Process (Nov. 16 & Dec. 12)

On November 16, 2016, CMS is hosting a call to provide an update on its latest plans to allow eligible providers to settle their inpatient status claims currently under appeal using the Hospital Appeals Settlement process. By way of background, this administrative settlement process will be available beginning December 1, 2016 for eligible hospitals that … Continue Reading

CMS Proposes New Rule in an Effort to Address Significant Medicare Appeals Backlog

The Centers for Medicare & Medicaid Services (CMS) recently issued a proposed rule to address the significant backlog resulting from “an unprecedented and sustained increase” in its Medicare appeals. According to CMS, the 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 … Continue Reading

HHS Proposes Rules to Streamline the Medicare Appeals Process to Address Backlog

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 … Continue Reading

GAO Highlights Significant Backlog in Medicare Appeals, Routine ALJ Failure to Meet Statutory Deadlines

The Medicare appeals process has not been able to keep up with an explosion in the number of volume, particularly at the administrative law judge (ALJ) level (Level 3), resulting in significant backlogs and widespread failure to meet statutory deadlines, according to a recent Government Accountability Office (GAO) report. Specifically, the GAO determined that Medicare … Continue Reading

Extensive Medicare & Medicaid Funding and Program Integrity Provisions in Obama’s Released FY 2017 Budget Proposal

On February 9, 2016, the Obama Administration released its proposed fiscal year (FY) 2017 budget, which contains significant Medicare and Medicaid reimbursement and program integrity legislative proposals – including $419 billion in Medicare savings over 10 years. These proposed policy changes would require action by Congress, and Republican Congressional leaders have already voiced general opposition … Continue Reading

OMHA Expands Settlement Conference Facilitation Pilot

The HHS Office of Medicare Hearings and Appeals (OMHA) has announced that it is expanding its Settlement Conference Facilitation pilot’s eligibility criteria to include more pending appeals. As previously reported, this pilot program is designed to bring the appellant and CMS together to discuss the potential of a mutually-agreeable resolution to claims appealed to an … Continue Reading

CMS Posts CY 2016 Amount in Controversy Thresholds for Medicare Appeals

CMS has published a notice announcing the annual adjustment in the amount in controversy (AIC) threshold amounts for Administrative Law Judge (ALJ) hearings and judicial review under the Medicare appeals process. Specifically, the calendar year 2016 AIC threshold amounts are $150 for ALJ hearings (the same as 2015) and $1,500 for judicial review (compared to … Continue Reading

MedPAC Report to Congress on Medicare and the Health Care Delivery System

The Medicare Payment Advisory Commission (MedPAC) has released its June 2015 Report to the Congress on Medicare and the Health Care Delivery System. The report includes a series of recommendations on Medicare hospital short-stay policy, in response in part to hospital concerns about related Medicare Recovery Audit Contractor (RAC) Program audits and appeals and the … Continue Reading

Senate Finance Committee Approves Medicare Appeals Reform Proposal

On June 3, 2015, the Senate Finance Committee approved by voice vote a bipartisan proposal to reform the Medicare audit and appeals process in an attempt to help ease the backlog of Medicare appeals and promote efficiency and transparency. The draft proposal, the “Audit & Appeal Fairness, Integrity, and Reforms in Medicare Act of 2015,” would, … Continue Reading

Congressional Health Policy Hearings

Congressional committees have held a number of hearings recently on health policy issues, include the following A House Energy and Commerce Health Subcommittee hearing on “Medicare Post-Acute Care Delivery and Options to Improve It.”  A Senate Commerce Committee hearing on “Advancing Telehealth Through Connectivity.” A Senate Finance Committee hearing on the impact of the ACA … Continue Reading

CMS Finalizes SMART Act MSP Appeals Provisions

The Centers for Medicare & Medicaid Services (CMS) has published a final rule that implements Medicare Secondary Payer (MSP) appeals provisions under the Strengthening Medicare and Repaying Taxpayers Act of 2012 (SMART Act). Specifically, the rule addresses the right of appeal and a new multilevel appeal process for liability insurance (including self-insurance), no-fault insurance, and … Continue Reading

President Signs Government Funding Bill with Health Spending/Policy Provisions

On December 16, 2014, President Obama signed a $1.1 trillion spending bill that funds most government agencies through the end of the fiscal year on September 30, 2015 (funding for the Department of Homeland Security is funded through February 27, 2015). With regard to HHS funding, the bill, among other things: holds CMS funding at FY … Continue Reading

HHS OMHA Soliciting Suggestions for Reducing Medicare Appeals Backlog

The HHS Office of Medicare Hearings and Appeals (OMHA) is seeking public comments on ways to address the substantial growth in the number of hearing requests being filed with OMHA and the backlog of pending cases. In particular, OMHA is seeking suggestions related to current OMHA initiatives or other recommendations for addressing the increased workload and/or backlog … Continue Reading

Update on CMS Medicare Appeals Administrative Agreement Offer

As previously reported, CMS is offering an "administrative agreement" providing partial payment to hospitals that drop their appeals related to certain short-stay hospital claims in an effort to reduce the backlog in Medicare appeals. CMS has posted updated “frequently asked questions” on its proposed settlement process. The deadline for applying for the settlement is October 31, … Continue Reading

HHS Office of Medicare Hearings and Appeals (OMHA) Hosting Second Medicare Appellant Forum (Oct. 29)

On October 29, 2014, the OMHA is hosting its second OMHA Medicare Appellant Forum. The meeting will update OMHA appellants on the status of OMHA operations and discuss OMHA and CMS initiatives designed to mitigate the Medicare appeals backlog at the OMHA-level of the administrative appeals process. The deadline for in-person registration is October 28, and registration for … Continue Reading

CMS Releases CY 2015 Amount in Controversy Thresholds for Medicare Appeals

CMS has published a notice announcing the annual adjustment in the amount in controversy (AIC) threshold amounts for Administrative Law Judge (ALJ) hearings and judicial review under the Medicare appeals process. Specifically, the calendar year 2015 AIC threshold amounts are $150 for ALJ hearings and $1,460 for judicial review. These amounts are effective for requests for … Continue Reading

CMS Offers Settlement to Acute Care Hospitals, CAHs to Resolve Patient Status Denial Appeals

In an effort to reduce the backlog in Medicare appeals related to certain short-stay hospital claims, CMS is offering an "administrative agreement" providing partial payment to hospitals that drop their appeals. Specifically, CMS would provide a payment equal to 68% of the net payable amount to acute care hospitals or critical access hospitals (CAH) willing … Continue Reading

July Congressional Health Policy Hearings

Congressional panels have held numerous hearings on health policy issues this month, including the following: The House Energy and Commerce Committee held a series of hearings on its “21st Century Cures” initiative, focusing on personalized medicine, barriers to evidence development and communication, technological innovations, the patient perspective, and modernizing clinical trials. A separate hearing focused on … Continue Reading

HHS “Settlement Conference Facilitation” Pilot Provides Alternative to ALJ Hearing

The HHS Office of Medicare Hearings and Appeals (OMHA) has announced the Settlement Conference Facilitation (SCF) program, a pilot alternate dispute resolution process designed to bring the appellant and CMS together to discuss the potential of a mutually-agreeable resolution to the claims appealed to an Administrative Law Judge (ALJ) hearing. If a resolution is reached, … Continue Reading
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