HHS proposes changes to appeal process

Thursday, June 30, 2016

WASHINGTON – The U.S. Department of Health and Human Services on June 28 issued a notice of proposed rulemaking on changes to the Medicare claims appeal process.

In the NPRM, HHS proposes additional administrative action to:

·      expand the pool of available adjudicators with the Office of Medicare Hearings and Appeals;

·      increase decision-making consistency among the levels of appeal;

·      and improve efficiency by streamlining the appeals process so less time is spent by adjudicators and parties on repetitive issues and procedural matters.

The changes address the second prong of a three-pronged strategy to address a major backlog at the administrative law judge level of the appeal process.

The strategy entails:

·      investing new resources at all levels of appeal to increase adjudication capacity and implement new strategies to alleviate the current backlog;

·      taking administrative actions to reduce the number of pending appeals and encourage resolution of cases earlier in the process;

·      and proposing legislative reforms that provide additional funding and new authorities to address the appeals volume.

If the administration implements the changes outlined in the NPRM, in conjunction with the proposed funding increases and legislative actions outlined in the FY 2017 president’s budget, HHS estimates that the backlog of appeals could be eliminated by FY 2021.

Stakeholders may comment on the changes until 5 p.m. EST on Aug. 29.