HHS Proposes Plans to Improve Medicare Appeals Process
Monday, July 11, 2016
by: Visiting Nurse Associations of America

Section: Public Policy and Advocacy

The Department of Health and Human Services (HHS) has issued a Notice of Proposed Rulemaking (NPRM) on changes to the Medicare claims appeal process. According to HHS, the proposed changes are to address the “unprecedented and sustained increase in the number of appeals and to eliminate the backlog of appeals currently pending at the Office of Medicare Hearings and Appeals (OMHA) and the Departmental Appeals Board (DAB).”  

Between fiscal year (FY) 2010 and FY 2015 the Office of Medicare Hearings and Appeals (OMHA) witnessed a 442 percent increase in appeals received annually and the Medicare Appeals Council experienced a 267 percent increase in appeals received annually. However, the amount of funding each entity has received has remained stagnant.

As a result, by the end of FY 2015, 884,017 appeals were waiting to be adjudicated by OMHA and 14,874 appeals were waiting to be reviewed by the Council. Based on current funding and resources, it is estimated that it would take 11 years for OMHA and six years for the Council to process their respective appeals backlogs.

HHS recently proposed a strategy to address the unprecedented backlog in appeals. In a recent Primer on the Medicare Appeals Process, HHS describes its strategy to address the appeals backlog as a three-pronged approach, which consists of:
  1. Investing new resources at all levels of appeal to increase adjudication capacity and implement new strategies to alleviate the current backlog.
  2. Taking administrative actions to reduce the number of pending appeals and encourage resolution of cases earlier in the process.
  3. Proposing legislative reforms that provide additional funding and new authorities to address the appeals volume.
The recent NPRM is HHS’s attempt to deploy the second prong of its strategy. In it, HHS proposes to: expand the pool of available OMHA adjudicators; increase decision making consistency among the levels of appeal; and improve efficiency by streamlining the appeals process so less time is spent by adjudicators and parties on repetitive issues and procedural matters.

Comments must be received no later than 5 p.m. EDT on August 29, 2016. VNAA plans to comment on the recent proposal and will provide our members with additional information in the near future. Please contact VNAA Vice President of Policy and Innovation Joy Cameron with any questions.
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