Medicare Appeals Backlog Continues to Increase

Question: Why are Medicare Appeals backlogs increasing? Is there any plan to tackle the backlog?
Answer: The Government Accountability Office (“GAO”) recently released a report finding that the Medicare appeals backlog continues to grow at an alarming rate. The current appeals backlog is increasing as the adjudication process is overwhelmed and unable to handle such volume. Experts agree that an increasing backlog will likely persist without a major structural overhaul to the Administrative Law Judge (“ALJ”) system that is currently in place. The GAO report cited enormous increases in Medicare appeals from fiscal years 2010 to 2014, including a 103% increase for Part B claims and more than 2,000% increase for Part A hospital claims. In addition, the GAO found that the number of appeals decisions issued after the general 90-day statutory time frame had increased and that Health and Human Services’ (“HHS’”) failure to capture more specific appeals data inhibited the agency’s ability to effectively identify the reasons behind the backlog and develop a meaningful solution. The healthcare industry and experts have long been critical of the increasing backlog in Medicare appeals, expressing serious concern with the processing delays. The number of appeals has skyrocketed, but the amount of funding for administrative law judges to decide them has not kept pace. The underfunding of the Office of Medicare Hearings and Appeals (“OMHA”) and the Medicare Appeals Council (“MAC”) is a serious issue as the number of incoming ALJ appeals in fiscal year 2015 was three times the number of decisions by OMHA judges that year. The council received no increase in fiscal year 2016, GAO noted, yet its pending workload is six times the amount it can adjudicate this year. While HHS and OMHA have implemented pilot programs aimed at tackling the backlog, the GAO’s report concludes that “while it is too early to predict the ultimate effect many of HHS’s current efforts will have on the Medicare appeals backlog, their effect thus far, with the exception of the global settlement, has been limited, and the backlog continues to grow at a rate that outpaces the adjudication capacities at levels 3 and 4.” 
Weekly Charting Tip:
If a patient uses foul language or threats, simply quote the language or the threat. Do NOT characterize the person who made the threat or used the foul language. If your M.A. or office manager heard the threat or language, have that person make a signed entry in that patient’s chart.
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