AHA: Proposal to ease Medicare appeals backlog a move in the ‘wrong direction’


recent federal proposal aimed at eliminating the backlog of Medicare appeals by 2021 would do little more than “scratch the surface of the problem,” according to the American Hospital Association.

In a letter sent to the Department of Health and Human Services’ Office of Medicare Hearings and Appeals on Friday, the AHA expressed skepticism that the office’s goal would give relief to healthcare providers whose appeals are stuck in administrative limbo.

“This projection is striking because it signals to providers with claims already delayed in the appeals process that they may expect to wait five more years before these claims can be resolved,” wrote Ashley Thompson, AHA senior vice president for public policy analysis and development.

Thompson’s letter cites recent statistics from the OMHA that put the average appeals processing time for the third quarter of fiscal year 2016 at 935 days. That reflected an increase of more than four months since the beginning of the fiscal year.

“This is movement in the wrong direction, and it is clear that merely tweaking the appeals system will not adequately address the problem,” Thompson wrote.

The letter takes aim at the Recovery Audit Contractor program, which the AHA said has been “consistently has downplayed” as an underlying cause of the backlog. Thompson urged the agency to implement controls that would limit RAC’s ability to deny claims and help prevent “the flood of inappropriate claim denials.”

Despite AHA’s assertions that RACs are to blame for the backlog, a recent report from the Government Accountability Office showed that few RAC cases are among those actually appealed, Kristin Walter, spokeswoman for the Council for Medicare Integrity, told McKnight’s.

“Medicare providers want to keep lining their pockets with improper payments, so it’s no surprise to see the AHA continue to make false statements blaming auditors for the appeals backlog,” Walter said. “It’s been well reported that the Medicare appeals backlog was caused by some Medicare providers appealing every claim denial in an attempt to game the system.”

Just over one-third of the 84,820 total claim appeals decided in fiscal year 2014 were appeals of RAC cases, Walter noted.

While overhauling the recovery audit process is not within OMHA’s control, Thompson’s letter recommended that the office continue to share data with federal health agencies and Congress to address the role RAC denials play in the appeals backlog.

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