Bush plan would make it tougher to appeal denials

Sunday, March 16, 2003

March 17, 2003

WASHINGTON - The Bush Administration plans to propose "major changes" to Medicare that would "make it more difficult" for beneficiaries to appeal the denial of certain benefits, the New York Times reports.

Under current federal law, independent administrative law judges employed by the Social Security Administration adjudicate appeals over the denial of Medicare benefits. The judges must adhere to Medicare law and rules but remain "insulated from political pressures and sudden shifts in policy made by presidential appointees," the Times reports.

The Bush administration plans to propose new rules, as well as legislation, that would limit the independence of the judges and could allow them to be replaced. The rules would require the judges to "give deference" to CMS policies and to companies that contract with the agency to review and pay Medicare claims. In addition, the rules would require Medicare beneficiaries to "show why such policies should be disregarded" in appeals over the denial of benefits, the Times reports.

Under the legislation, HHS attorneys or hearing officers, as well as arbitrators or mediators, could adjudicate the appeals, rather than administrative law judges. Medicare officials could adopt the proposed rules without congressional approval; the proposed legislation would require approval from Congress. The Bush administration also hopes to transfer responsibility for the adjudication of Medicare appeals from SSA to CMS by Oct 1. A bill introduced this year by Rep. Nancy Johnson (R-Conn.) would make the transfer in 2005 but would require the HHS secretary to maintain the independence of the judges who adjudicate Medicare appeals.

HHS Secretary Tommy Thompson said that the proposed rules and legislation would provide the department with the "flexibility to reform the appeals system" for Medicare and allow the government to decide cases in a more "efficient and effective manner." HHS officials added that the proposals would address an "urgent need for improvements to the Medicare claim appeal system" because of the increased number of appeals filed in recent years.

However, administrative law judges and consumer advocates criticized the proposals. Ronald Bernoski, president of the Association of Administrative Law Judges, said, "We see President Bush's proposals as ... a stealth attack on the rights of citizens to fair, impartial hearings. These hearings guarantee due process of law, as required by the Constitution." Judith Stein, director of the Center for Medicare Advocacy, added, "The president proposes replacing administrative law judges with some form of dispute resolution. This puts beneficiaries at a disadvantage, with unequal bargaining power and inadequate expertise to do battle" with CMS.

In the past year, beneficiaries and providers won more than half of the 77,388 Medicare appeals decided by administrative law judges; they won in 53% of the Medicare appeals filed over the past five years. In 2000, Congress passed reforms to the Medicare appeals process to increase the rights of beneficiaries and "expedite decisions," but CMS has delayed many of the reforms because of a lack of funds, the Times reports.