Medicare Appeals Forum Spotlights Inefficiency of Medicare Appeals Process


February 13, 2014

Medicare Appeals Forum Spotlights Inefficiency of
Medicare Appeals Process

ACHCI echoes provider concerns, urges immediate ALJ Reform

Washington, D.C. The American Coalition for Healthcare Claims Integrity (ACHCI) today issued a statement regarding the information and insights shared at the Office of Medicare Hearings and Appeals (OMHA) appellant forum on Feb. 12, 2014. OMHA officials used the day-long forum to explain the rationale behind the recent suspension of Medicare appeals assignments, and to solicit feedback from contractors, providers and beneficiaries.

“Our coalition appreciates the efforts made by the Office of Medicare Hearings and Appeals (OMHA) to remedy the Medicare administrative law judge (ALJ) backlog and improve the appeals process overall,” said Becky Reeves, spokeswoman for the coalition. “Our central concern remains the inconsistency of ALJ reviews and decisions. Recovery Audit Contractors (RACs) strictly adhere to Medicare policy, as evident by their average accuracy rate of 95%.[i] While we welcome many of the proposals presented by OMHA officials to address this issue, such as the adjudication manual and ALJ educational symposia, we will continue to push OMHA to impose strict Medicare compliance requirements on the ALJ.

“On this issue, our coalition stands with providers. ALJ delays tie up critical resources, undermine Medicare integrity and threaten long-term access to care. These problems largely stem from a lack of alignment between the ALJ and lower levels of appeal. Opening more effective lines of communication across all levels of appeal, promoting case resolution at the lowest level, and enforcing Medicare policy would immediately improve the appeals process. We urge OMHA to consider these options and expedite its plans for ALJ reform.”

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

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[i] Recovery Auditing in the Medicare and Medicaid Programs for Fiscal Year 2011. The Centers for Medicare and Medicaid Services, Feb. 2012.  Pg. 32. Web. <http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Downloads/FY2011-Report-To-Congress.pdf>.

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