News: New rules aim to cut down Medicare claims-appeals backlog

The new rules for Medicare claim-denial appeals feature several changes crafted to ease administrative burdens and speed reductions in a backlog nearing one million cases, HealthLeaders Media reported.

Three officials at the Office of Medicare Hearings and Appeals (OMHA) led a Medicare Learning Network presentation to walk healthcare providers through the changes in the claim-denial appeals process at the ALJ level on Thursday, June 29.

The presentation last Thursday featured seven changes to the. All the changes are designed to either quicken or streamline adjudication. The changes include:

• Attorney adjudicators: A new position at the ALJ level created to help clear the appeal backlog.
• OMHA-100 form: The user-friendly form helps users walk through the information required to make a valid request to for ALJ hearings.
• Statistical Sampling Initiative: Allows a random sampling of claims for review in an ALJ hearing.
• Party limit: The limit applies to cases where multiple entities could be parties in the appeal helps streamline the process.
• Aggregating appeals: The option limited to requests made at the same time appellants ask for a hearing in the claims they want to aggregate. 
• Dismissal authority: An attorney adjudicator or ALJ can now vacate the dismissal or a request for a hearing or a request for a review rather than requiring an appeal from the appellants.
• Time or place of hearing objections: The new rules allow for last minute hardships such as allowing oral rather than written notice of emergencies on the day of the hearing or the previous day.

 “The final rule streamlines administrative appeal processes, increases consistency in decision making across appeal levels, and improves efficiency for both appellants and adjudicators,” according to the fact sheet from the Department of Health and Human Services.

Editor’s note: To read more about the Medicare appeals backlog, click here. To read more about clearing the appeals backlog, click here. To learn more about denials and appeals, check out the “CDI Field Guide to Denials Prevention and Audit Defense” by Trey La Charité, MD, FACP, SFHM, CCDS.