RACFacts: AFIRM: What You Need To Know

AFIRM: What You Need To Know

The Senate Finance Committee is to be congratulated for its important work navigating a complicated system and undertaking much needed changes to the Medicare appeals process, as reflected in the Audit & Appeal Fairness, Integrity, and Reforms in Medicare (AFIRM) Act of 2015.

The Council for Medicare Integrity is encouraged by the Committee’s focus to reduce the now historically high of level of improper Medicare payments which have drained more than $46 billion from the Trust Fund in FY2014.

We support:

  • Sending claims back to the first level of appeals when new evidence is submitted later in the process
  • Creating Medicare Magistrates to handle smaller appeals amounting to less than $1,460
  • Requiring HHS to study whether it would be feasible to increase CMS or contractor participation in appeals hearings, including providing notice of a hearing to contractors

We recommend: 

  • Inclusion of a refundable filing fee, as championed by the President’s budget, Secretary Burwell and Chief ALJ Griswold, to strengthen the bill
  • In absence of the 3-year look-back period, penalties for providers who fail to bill a claim within 3-months of date of service
  • Expedition of claims where no facts are disputed, allowing both the ALJs and magistrates to issue decisions based on the record (OTR) without holding a hearing
  • Allowing RACs to submit a written brief for all OTR decisions

We are awaiting more details on certain issues, such as:

  • If a one-year audit holiday for providers with a “low error rate, unless there is evidence of systemic gaming of the system” is put in to place, how would we operationalize this criteria?
  • What is the error rate threshold that would render a provider exempt from being audited by both RACs and MACs?
  • How would evidence of systemic gaming of the system be determined and what would be the criteria for that?
  • Will there be any oversight to ensure that gaming of the system does not occur during


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