News: AHA to develop Medicare appeal backlog fixes, judge says
A federal judge asked the American Hospital Association (AHA) for ideas on how the Department of Health and Human Services (HHS) can work through its Medicare billing appeals backlog, Modern Healthcare reported.
As of June 2017, the Office of Medicare, Hearing and Appeals (OMHA) had 607,402 appeals pending with an estimated wait time of three years for an administrative law judge to process a provider’s appeal. At this rate, according to Modern Healthcare, the backlog is predicted to reach 950,520 appeals by the end of fiscal year 2021.
In light of these staggering numbers and the AHA’s repeated pleas for action, U.S. District Judge James Boasberg told the AHA to provide the court with a list of recommendations to eliminate the backlog by June 22. HHS will then have until July 6 to respond to the AHA’s suggestions.
Sean Marotta, an attorney for the AHA and senior associate at Hogan Lovells, told Modern Healthcare last week that the association will suggested that CMS impose financial penalties on Recovery Audit Contractor (RA) if the majority of their denials are overturned on appeal.
Currently, RAs have strong financial incentives to deny claims, Marotta said—a problem any CDI program investigating denials knows all too well.
The AHA may also suggest that HHS eliminate the RAs’ ability to deny claims based on medical judgement and transfer such cases to another type of Medicare contractor who tend to be clinicians, according to Marotta. In fact, Marotta said that he hopes all hospital claim reviews will eventually be reviewed by Quality Improvement Organizations rather than the RAs.
The RAs “are very eager to ramp up and review new claims,” said Marotta. “We’re afraid they are going to go after hospitals again, as that’s what they’ve done in the past.”
Editor’s note: To read the coverage of this story from Modern Healthcare, click here. To read about the current denials landscape and tips for how CDI can get involved, read this article from the March/April edition of the CDI Journal.