Audit bill clears committee

Thursday, June 4, 2015

WASHINGTON – The Senate Finance Committee on Wednesday passed a bill to improve the Medicare audit and appeals process.

The bill, the “Audit and Appeal Fairness, Integrity and Reforms in Medicare Act” or AFIRM Act, was co-authored by Sen. Orrin Hatch, R-Utah, chairman of the committee, and Sen. Ron Wyden, D-Ore., ranking member.

“This is a common sense bill that will help untangle the web of red tape that ensnares the current audit and appeals process and guarantee Medicare patients continue to have access to high-quality care,” Hatch stated in a press release. “I look forward to continuing to work with my colleagues on both sides of the aisle to move this bill forward.”

The AFIRM Act seeks to strengthen the current process in the following ways:

·      Improve oversight capabilities for HHS and CMS that increase the integrity of the Medicare auditors and claims appeals process.

·      Coordinate efforts between auditors and CMS to ensure that all parties receive transparent data regarding audit practices, improved methodologies over time, and new incentives/disincentives to improve audit accuracy. CMS would create in independent ombudsman for Medicare reviews and appeals to assist in resolving complaints by appellants and those considering appeal. This ombudsman would further increase the transparency of the appeal process by publishing data regarding the number of determinations appealed, each appeal’s outcomes, and aggregate appeal statistics for each contractor and provider type.

·      Establish a voluntary alternate dispute resolution process to allow for multiple pending claims with similar issues of law or fact to be settled as a unit, rather than as individual appeals.

·      Raise the amount in controversy for review by an ALJ to match the amount for review by district court to ensure timely and high quality reviews. For cases with lower costs, a new Medicare magistrate program would be created to allow senior attorneys with expertise in Medicare law and policies to adjudicate cases in the same way as the ALJs. This would allow more complex cases to retain the full focus of the ALJs.

·      Allow for use of sampling and extrapolation, with the appellant’s consent, to expedite the appeals process.

Industry stakeholders are also working with Rep. Renee Ellmers, R-N.C., to introduce a bill in the House of Representatives that would, among other things, reinstate clinical inference as part of the audit process.