Changes to the Medicare Appeals Process

August 25th, 2017 - Sean Weiss, CHC, CMCO, CEMC, CPMA, CMPE, CPC-P, CPC
Categories:   Medicare   Denials & Denial Management  
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On June 29th, The Centers for Medicare and Medicaid (CMS) issued the Medicare Program: "Changes to the Medicare Claims and Entitlement, Medicare Advantage and Organization Determination, and Medicare Prescription Drug Coverage Determination Appeals Procedures final rule." The purpose of this guidance is to streamline the administrative appeal processes, increase consistency in decision making across appeal levels and improve the efficiency for both appellants and adjudicators, and in particular benefits Medicare beneficiaries by clarifying processes and adding provisions for increased assistance when they are not represented.

Because there has been such a significant increase in the number of appeals filed to the ALJ (at the end of 2016 there were more than 650,000 pending appeals at OHMA) and the lack of funding by the congress, there is significant backlog at the ALJ and DAB (MAC) levels. Personally, I blame the significant and sustained increase in appeals on Medicare's use of contractors (ZPIC (now UPIC), MIC, MAC, RAC, etc.) who, more often than not, are issuing findings against medical providers that are bizarre and fail to adequately explain why a service is being denied in part or in whole, which leads to the filing of appeals.

If these contractors would assign individuals with the requisite skills in the specialties they are auditing, I fully believe the number of appeals for denials would be cut by a significant percentage. If you are interested in seeing where things currently stand with the backlog, The Medicare Appeals Process is available on OMHA's website at:

Here is a small excerpt from this document explaining the issues:

"In fiscal year (FY) 2016, more than 1.2 billion Medicare fee-for-service claims were processed. On initial determination, over 119 million claims (or 9.7 percent) were denied. Of the denied claims, 3.5 million (2.9 percent of all Medicare denied claims) were appealed. In recent years, OMHA and the Council have received more appeals than they can process within the contemplated time frames. From FY 2010 through FY 2015, OMHA experienced an overall 442 percent increase in the number of appeals received annually. In the same time frame, the Council experienced an overall 267 percent increase in the number of appeals it received annually. However, while the volume of appeals has increased dramatically, funding has remained comparatively stagnant. As a result, as of the end of FY 2016, 658,307 appeals were waiting to be adjudicated by OMHA and 22,707 appeals were waiting to be reviewed at the Council. Under current resource levels (and without any additional appeals), it would take eight years for OMHA and ten years for the Council to process their respective backlogs.

Changes to the Medicare Appeals Process:

"The changes in the final rule are primarily focused on the third level of appeal and will:

While these changes are significant and aim to reduce the number of appeals and the timeframe in which appeals can/will be heard; it is important to keep in mind this is only a first step by CMS and the process as with all things tied to the government will most likely need to be overhauled or at least tweaked to allow appellants and adjudicators the ability to understand the process and to ensure due process for appellants.


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