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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) is increasing the amount in controversy (AIC) threshold amounts for Administrative Law Judge (ALJ) hearings and judicial review under the Medicare appeals process for 2020.  The CY 2020 AIC threshold amounts are:

  • $170 for ALJ hearings (compared with $160 in 2019), and
  • $1,670 for judicial review (up

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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

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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…

On January 9, 2018, CMS is hosting a call to discuss its new low volume appeals settlement option. As previously reported, this option is available for certain Medicare fee-for-service providers, physicians, and other suppliers with fewer than 500 appeals pending at the Office of Medicare Hearings and Appeals and the Medicare Appeals Council at…

The HHS Departmental Appeals Board (DAB) is inviting the public to submit recommendations for precedential Medicare Appeals Council (Council) decisions that will be binding on all CMS, HHS, and Social Security Administration components that adjudicate matters under CMS jurisdiction. The designation of precedential decisions was authorized by regulations adopted earlier this year; the DAB…

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…

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…

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

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…

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…

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

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…

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…

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…

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…