Hearing Clarifies Status of Medicare Appeals Process


July 11, 2014

Hearing Clarifies Status of Medicare Appeals Process

Judge Griswold spotlights low rate of overturned cases related to the RAC program

Washington, D.C. – The American Coalition for Healthcare Claims Integrity (ACHCI) today issued a statement regarding a hearing held by the U.S. House of Representatives Oversight and Government Reform Subcommittee on Energy Policy, Health Care and Entitlements. The hearing focused on the status of the Medicare appeals system and the current backlog of appeals cases, with the Office of Medicare Hearings and Appeals (OMHA) Chief Administrative Law Judge Nancy Griswold serving as the sole witness.

“Today’s hearing provided much needed clarity around the status of the Medicare appeals system,” said Becky Reeves, coalition spokesperson. “As stated by Chief Administrative Law Judge Nancy Griswold in her testimony, ‘the Recovery Audit Program, established by Congress, has been very successful, returning billions in improper payments to the Medicare Trust Fund. Only 7% (99,492) of the 1.419 million Recovery Auditors claims identified as overpayments were challenged and overturned on appeal as published in the Centers for Medicare and Medicaid Services (CMS) FY 2012 Report to Congress.’

“Our coalition also appreciates the committee members’ efforts to debunk the ongoing myth that Medicare integrity contractors have acted outside of their authority and caused the spike in appeals. As stated by Rep. Jackie Speier, Congress mandated recent increases in Medicare oversight activities – leading to an increased volume of appeals – and the RAC program has led to the exposure of many questionable billing practices by providers. Further legitimizing the RAC program, Rep. Speier also noted that rates of overturned RAC cases decrease dramatically when CMS or a recovery auditor attends a Medicare hearing, signaling a lack of consistency in the judge’s evaluations. Furthermore, as lawmakers and other Medicare stakeholders strive to limit the administrative impact of program oversight on providers, the central integrity functions of the Congressionally mandated RAC program must be preserved.

“Delays in the Medicare appeals process pose significant challenges to Medicare integrity. In an effort to limit the impact of these developments on seniors, providers and contractors, our coalition recommends continuing to impose strict Medicare policy compliance requirements on judges to ensure consistency across all levels of appeal; requiring OMHA to produce regular reports with data on pending cases, overturn rates and case volume; improving notification procedures to ensure integrity contractors are given ample time to plan for and attend a hearing; and finally, we echo Rep. Speier’s recommendation to expand OMHA resources to allow the agency to hire additional judges and expedite other system enhancements. These solutions would provide immediate relief to the appeals backlog and foster transparency among all Medicare stakeholders.”

For more information, please visit: www.properpayments.com

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