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In the event a Medicare claim is denied, the Department of Health and Human Services provides applicants with a five-level appeals process, including redetermination, reconsideration, hearing before an administrative law judge, review by the Medicare Appeals Council and, lastly, judicial review in a federal district court.

As orderly as this process may seem to the uninitiated, the HHS has recently come under fire from beneficiary advocacy groups, medical providers and even the Government Accountability office for both the glacial pace of the appeals process and its inability to reduce the appeals backlog, which has now grown to over 700,000 cases.

Indeed, a judicial officer with the Office of Medicare Hearing and Appeals recently indicated that if no changes were introduced to the system and no more appeals were filed, it would still take an astounding 11 years to clear the backlog.

A significant part of the problem, say experts, is at the third level of appeals -- the ALJ hearing -- as cases can wait for a rather lengthy amount of time to be heard. Even then, once the hearing is held, decisions are not being issued for an average of a little over two years.

In recognition of this problem, the HHS has introduced some proposed changes to the appeals process that agency officials claim will eliminate the backlog within five years.

These proposed changes include:

  • Enabling senior agency attorneys to handle purely procedural matters that currently must come before ALJs
  • Revising the manner in which the minimum amount needed to file an appeal is calculated
  • Designating certain decisions from the Medicare Appeals Council as binding precedent as a means of resolving inconsistencies and reducing unnecessary appeals
  • Doing away with certain steps in the appeals process

While these efforts are being championed by the HHS as an effective way to streamline the appeals process, others are more skeptical. Indeed, some are arguing the proposals would prove to be unduly punitive to applicants and would fail to speed up the process.

The proposed changes will soon be posted to the Federal Register for public comments.

Stay tuned for updates …

If you would like to learn more about your rights and obligations as they relate to Medicare or other compliance-related issues, consider consulting with an experienced legal professional.

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