A half-dozen changes to the adjudication of Medicare claims-denial appeals are designed to ease a festering backlog of cases.
The new rules for Medicare claim-denial appeals feature several changes crafted to ease administrative burdens and speed reductions in a backlog nearing 1 million cases.
The new rules went into effect March 20. "This final rule streamlines administrative appeal processes, increases consistency in decision making across appeal levels, and improves efficiency for both appellants and adjudicators," a Department of Health and Human Services fact sheet on the new rules says.
Thursday afternoon, three officials at the Office of Medicare Hearings and Appeals (OMHA) led a presentation to walk healthcare providers through more than a dozen significant changes in the new rules. OMHA reports directly to Health & Human Services Secretary Tom Price, MD.
Disputed Medicare claims of more than $160 can be appealed to Administrative Law Judges (ALJs) and attorney adjudicators for reviews that can include a hearing. The last stop before federal court is the Medicare Appeals Council.
Thursday's Medicare Learning Network (MLN) presentation featured a half-dozen changes to the claims-denials appeals process at the ALJ-level that are designed to either quicken or streamline adjudication:
- Attorney adjudicators are a new position at the ALJ level created this year to help clear the appeal backlog. "Attorney adjudicators are not authorized to conduct a hearing, which also means they cannot issue a decision in any case where a hearing is necessary," said Jason Green, JD, chief adviser at OMHA. "However, attorney adjudicators can issue decisions when a hearing is not required, including cases where the records support a fully favorable decision."
- OMHA-100 form: This new form "is user-friendly and helps walk you through all the information required for a valid request for ALJ hearings," OMHA's Amanda Axeen, JD, said during the presentation. OMHA-100 can be used to request new hearings or review of appeal dismissals. The new form is not mandatory as long as previously required documents and information are filed.
- Statistical Sampling Initiative: This new option for appeal adjudication "draws a random sample from a universe of claims and extrapolates—or projects—from the sample to the entire universe of claims," OMHA's Anne Lloyd said during the presentation. For example, she said a statistician could pick a sample of 30 claims out of a total of 1,000 for review in a ALJ hearing.
"A decision is made on those claims, and then the decision on those claims is extrapolated back to your 1,000-universe of claims that you started with," she said. Healthcare providers can't "cherry-pick" appeal cases to be included in the statistical sample, she added.
- Party limit: "When multiple parties participated in the same hearing, the hearings not only took longer and were more challenging to coordinate, they also could become more adversarial," Axeen said. Under the new rules, if there are multiple entities that could be parties in an appeal, the first to file is the party of record for a hearing, with the remaining entities designated as non-party participants. However, an ALJ has discretion to allow any entity to be represented at a hearing.
- Aggregating appeals: OMHA has tightened the rules for aggregating multiple appeals into one case. "In the past, appellants sometimes filed the request for hearing on one claim with the request to aggregate that claim with another claim in an appeal that had already been filed. Because of the logistics … and the appeals backlog at OMHA, this is administratively burdensome," Axeen said. Under the new rules, aggregation has to be requested at the same time appellants ask for a hearing in the claims they want to aggregate.
- Dismissal authority: "An attorney adjudicator or ALJ may vacate the dismissal of a request for a hearing or a request for a review. Previously, appellants had to appeal any dismissal from the ALJ-level, which was time-consuming and inefficient," Green said.
- Time or place of hearing objections: The new rules allow for "last-minute" hardships such as allowing oral rather than written notice of emergency circumstances the day of a hearing or the day before.
Christopher Cheney is the CMO editor at HealthLeaders.