Council for Medicare Integrity Urges Congress to Pass AFIRM Act

Council for Medicare Integrity Urges Congress to Pass AFIRM Act

Reform Needed to Repair Besieged Medicare Appeals Process

Washington, D.C. – Today, the Council for Medicare Integrity (CMI) is asking Members of Congress to take swift action to pass the Audit and Appeals Fairness, Integrity and Reforms in Medicare (AFIRM) Act. Passed by the Senate Finance Committee last year, AFIRM seeks to make urgently needed programmatic changes to help address the backlog of 560,663 cases waiting for review in the U.S. Department of Health and Human Services (HHS) Office of Medicare Hearings and Appeals (OMHA) process.

The AFIRM Act would ensure active steps are taken to address the backlog by sending claims back to the first level of appeal when new evidence is introduced later in the process.  It would also create Medicare Magistrates to perform reviews and render decisions on certain types of cases, and ensure fairness by requiring that all parties involved be notified in advance of a hearing to allow for participation of all stakeholders.

“Some Medicare providers continue to actively seek to collect millions in improper payments from the program,” said CMI spokesperson Kristin Walter. “They flooded the system with meritless appeals, causing the backlog, while inexplicably laying blame at the feet of those mandated by Congress to ensure that providers adhere to Medicare billing policy.”

The current backlog of appeals has been widely credited to a small number of Medicare providers that dispute nearly every claim denial at the Administrative Law Judge (ALJ) level in an attempt to game the system and secure higher payouts. Unlike other levels of appeal in the process, ALJs have broad discretion and do not have to follow Medicare policy – spawning an epidemic of “frequent filer” providers.  According to Chief ALJ Nancy Griswold, 51 percent of appeals filed in 2015 were filed by the same five appellants.

“The Recovery Audit Contractor Program has been proven a successful tool in identifying and returning improper Medicare payments and has an independently-validated accuracy rate of more than 95 percent,” said Walter.  “It’s time to put safeguards in place to prevent providers from flooding the appeals process. It’s time to pass AFIRM to shore up the program and move backlogged cases through more efficiently.”

While the AFIRM Act addresses several issues facing the struggling Medicare appeals process, CMI recommends some additional safeguards to further promote expediency and prevent future backlogs, specifically:

  • Inclusion of an appeals filing fee, refundable if a provider wins its appeal, as championed by the President’s Budget, the HHS Secretary and Chief ALJ;
  • Penalties for providers who fail to bill a claim within 3 months of the date of service;
  • Requirements recommended by Congress that ALJs make decisions consistently and in accordance with Medicare policy; and,
  • Expedition of claims where no facts are disputed.

“We applaud members of the House and Senate who have championed the AFIRM Act,” said Walter.  “This is an important priority to CMI, even with HHS recently noting that RACs are not, and have never been the primary source for the backlog. We urge Congress to focus their immediate attention to this important issue after the election.  The Medicare program and American seniors are counting on it.”

Congress mandated the creation of the Recovery Audit Contractor (RAC) Program to review Medicare claims, identify billing errors and return mis-billed funds back to the Medicare Trust Funds. Since the program began in 2009, RACs have returned more than $10 billion in improper payments and more than $800 million in underpayments back to providers. Recovery auditing has been credited with extending the life of the Medicare program by two full years.

For more information, please visit: www.medicareintegrity.org.

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About the Council for Medicare Integrity
The Council for Medicare Integrity is a 501(c)(6) non-profit organization. The Council’s mission is to educate policymakers and other stakeholders regarding the importance of healthcare integrity programs that help Medicare identify and correct improper payments.



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